Cr@Et/Renzi                                   OF
          8 7 t')
                  2                               PUj'@'LIC       SER@VICE


                                                        @l'IITZjJj liBALTII ADI.'INISTI@A21ON
                  3           IIEI@LTII SEIZVICES AlqD 1'1,,


                  4                          I)X- GION7i.T-t 14F@DICAL PROGIU-il-IS


                  5                                       - - -


                  6                                Review Conuiii-ttc-e


                  7


                  8


                  9

                 10                                            Conferenc-. Room Gl.'i
                                                               Pztrklc,@.,,n Buil6ii-ig
                                                               Roclc%rille,
                                                               Thursday, May 4, 1972
                 12
                                  The r,,eetii-,g conveil,&,d a'L-1 C@-.4'j o'cloc;l@-
                 131
                 141            I-layer presidiricj.
                      Council Merbers Present:
                 15
                                  Dr.   Gladys    Ancrum
                 16               Miss Dorothv Aiidersoii
                                  Sist,er Anii Jo,.opl,iine
                 17               Dr.  Gerald    El-sson
                                  Dr.  G. V.  B):indl,.ey
                 181              Dr.  Effie   0.   Ellis
                                  Dr.  J o F, c @'c s s
                 19
                                  Dr.  Jolin
                 20               Dr.  llill-i@ari 1.1a,,rcr
                                                   .1
                                  Mr.  J'eznus Pa,--ks
                 21               Dr.  Leoiiai:d Schcr5.,."..-,
    t                             Dr.              !I. C.,clin-,,i-dt
                 22               Dr.  @litchell Spell)ii@n
                                  Dr.  Will4-@.m Thur,-rLin
                 23               Dr.  Phili.r, Wliii-e

                 24

  kce     Reporters, Inc.
                 25






























                                                   TRANSCRIPT


                                           REVIEW COMMITTEE MEETING
                                                 May 4-5, 1972
                                                   Volume II





                                                                    Mr. Nash




                                                                                                                           2




                                                                       CONTI!',IITS
                           2 LlendzL T'c--,r,,i                                                                            P- ) e
     o
                           3 Corru'@nclits ):)y liar-old Margul:Les                                                            3
                           4 Future l@eeting Dzites            .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .        37
                           5 Commc-rits by  Dr.  lierb Pahl            .  .  .  .  .  .  .  .  .  .  .  .  .  ..  .        39
                           6 @enal Program - Dr.  Hinmaii                .  .  .                                           69

                           7 Consideration of Applications:
                           8         Oregon                                                                                94
                           9         Ohio                                                                                 137
                           10        Northeast Ohio           .  .  .  .                                                  16   7
                           I I       lassau-Suffoll@          .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                 209
                           12        No;')ras  I:a                                                                        2 4- 2

                           13'

                           14


                           15


                           16


                           17


                           18


                           19


                           20


                           21


                           22


                           23


                           24

    Ace-Fedetal Repoiters, Inc.
                           25




                                                                                   3



                                     P R 0 C B E D I N G S
                  2           DI.Z. MliYER: I thi),-ilc xjo rtii.glit begin. Pi-- some of you
                  3 are aware, there are four of'us who will not be with you at
                  4 the next meeting.  2ULd I note- that all four of us are- riTor-ousll.
                  5 in attei),dz)jice and on time.  Paid as a co:isequ-oyice of that, I
                  6 thought we might commence and pick up the others as we go

                  7 along.
                  8           Hopefully,  because of the changes that are here and
                  9 that we have laboriously @@,,orlied at and staff has laboriously
                  10 worl-.ed at, maybe we might be r)ble to get thro@igl-i without N..,o--kinc
                  11 'all night tonight and witlAout starting at 7 or so in the
                  12 mo-@iiiiig but at a reasolliAb'ie time.
                  13          A g)ceat deal has           siiicc-, the I.azt mectii".g of
                  14 this committee. Harold kindly did send us an interii-,i repo.,:,L-. and
                  151 try to keep us up to date on it.  I would have to say that my
                  16 grapevine suggests that evcn silence that interim reportf a
                  17 hecl,@- of a lot has happened.  Arid I thought I understood what
                  18 a rapi-d rate of chanae      ll:xrold, but X must adnit that I
                  19 aiA developing a new perfective on how          t,-Iiat change. is-

                  20 and the degree of that slope.
                  21           Ilith. that,, let rc turn it over to Harold l@largulies

                  22 -Jr--or comments.

                  23           Harold.
                  24           DR. liAlIGULIESz  Thank you ve)--y mu%-.h.

  Ace-Fedeial Repottefs,  Inc.
                  25           The title of this presentation is "Prc@,@jent Shock."




                                                                                      4


                 1  Thr--re zirc a nurtiber of      I woul-d l,ilzc to qO Over        You,
                 2  but before I do and at 'the         of saxying the obvious, I %@ould
                 3  like to co,-carLc@rLt. on the fact i-,he,.t 'cl-ic c-,nei of -Llio T?-"riod of
                 4  activity of the foi-i2: people %-@ho have b-,--n --c-y.-%!,ing on the
                 5  review             is a point o'L  real  concern  for  all  of  us.
                 6  1 was just talking to  Bill  @@@lio  confessed  to  something  like
                 7  six years and  six  months  with  the  R-agi.onal  Yedical  Program
                 8  which should represent some kind of a badge of honor, purple
                 9  hecirte or -,oinnzth4@ng oil- that I-Iiiid or purple heart for each
                 10 year, but it is going to make a big cli@-nge,  Arid it is going
                 1 1-to be a rioi;abl-c- long when we Fee these very,, ve,-ry effect@.ve

                 12  r)eopIL- lc,.@ve
                               7@id it doas not-.Ytipv-r,,of coursc-, that w,,- Front
                 .14 anticipate being cable to call  on  them  regularly  cis  we  have
                 15 with  others  who  have  served  on  both  committee  and  Comci-I.
                 16  And we don't e@,pect to let tJ,-ien, leave the-, progr@zin that

                 17 effectively.
                 18             1 woLild like to bring you up to date on a series of
                 19  events which  are  not  necessarily  related,  but  all  of  which
                 201 have a heavy impact on  our  activities  and  on  the  r%.Ggionz%l

                 21  IIc--dic,-tl Programs.
                 22             'First,  let's  start  with  the  current   legislative
                 23 ii-ricerest @,.-Yiich sud,2@,nly   into a point of great concern
                 24  and peop).e realized thz-it tli(! l@ccyiona.1 I@IL-dicz-@l Program

  Ace-Fedctal  R(@portefs,  Inc.
                 25  legislation  along  with  just  about  every   major   legislative





                       I pr                                             orts P"o@:,,rains in 1'c@alth
                                                          1,71 i,ch

                       2 E-,ervice2;; end         Fca  it-ii                          I-ir.) foL- c.,,.teiLs,-on
                       3 during the coming f4&scal @vcar.          I          thc,,):e are at le,,77,. c, t
                       4 14 major health legislative acts Glitch have to be renei,;ed by
                       5 Ju-re 30 of 1973,      nl,,iP i@- one of them.
                       6              I don't believe that the Adniinistra.ti.on has estab-
                       7 lishad  a  clear  position  on   the   whole   range   of   therLi,   but   it   has
                       8 made it clear in the first response to Senator Kennedy's
                       9 bill ti-iat it'hored to eddrc.@ss the legislation this t4-nie in a
                       10 much more                      fashion   ri@ther   than    having    a    separate
                       11 'extension  of  Acts  @qhich  have  come  to  lipv-o-  -i  relationship  wi,,'--Il.

                                  them, b          c-- cc    c,
                       1 2one ano          --it wc,,          d      ct              i-)o-nt in tiiii-3
                  .13  withou-'k,-, that                   clearly -.pollod out.
                       14             I,?hzit d4-d hempen is thF.-c.  wl-tcn  Sonat:or  IN'eni-iody  iritro-
                       15  duced his  bill on llcaltl-l                                       he reiO-cd
                       16  to it fo@- purposes   of   opening   the   discussion    tJ-ie    extension    of
                       17  several of tile legislative Acts.   And Title IX for Regioi-ial

                       18 Medical Progrz?.-r,,Ls was one of tl-i'em,
                       19             I believe thE'@t hearings        are already unden.@,ay anci
                       20 i,7ill continue.    I don't lesson the forRiat in which they                    be
                       21 carried out.   There have been discussions -i.n.,jidc-! I-IEW siia,,oly
                       22 leading  up  to  what  the  legi@@slative  form   of   the   r@,.IP   shoLild   be.
                       23 The coordinators independently have sugge.@,ted cctrta.in legislat-i@
                       24 bases  for r@gional liedi,cal Prog@-aris  !7;,o  th,v@@t-  tl,,ir-,  Hill  have  a

   Ace-Fedc-ial      Repoitefs, Inc.
                       25 very clear-cut influence on l@ihat ",,a do in the future.




                                                                                                                                               6



                                                                                                   N'@, icil yoli leave
                               1                    The issues are all Ulos                          II
                               2   here in the                                              Tlicy  j:,eise  t' c,.-  que@@t4 on.@,  of
                               3   how P@IP rctl@,@'-,ed@, to                                    1-i.ealth plc.,nz-.ing.           T I-)@y
                               4   raise  the  question of  the                                            of  the  Na,--ional  Iledical
                               5   Prograras  to  educational                                        to  the  implementation  of
                               6   planning,  to  the  categorical  devices  which  have been  a  p@-rt
                               7   of  PdviP  since  its  beginning,  @nd  to  a  iiu,,ilDer  of - other organiza-
                               8   tiorial  issues  which                       pi-ob@@,,Ialy  c@.rry  the  dc--@bate  until  well
                               9   after  the  election.    I  woi-ii-d  b,--  su.%-p3-.,i&ed  if  there  is  tiny
                               I 0 final zctioii on oil-.r                                    -Lin,'Cil  someti.mp-  ,after  tli@.  next
                               11  -Congrers                      Bu-Il-,,  of  cou.@cse,  it  is  concoivz,,ble  it  coul@d
                               12  b(-.  do,,i,-  in  t-l-ic-.  I?:cc,@ent-                       It  ir,  conceivable,                      vel-Y

                               13  dou-btft,.I.
                               14                    1  also  don't  kiiow  home much  the  Ilousc-  cn-i-id  Sci-ialt--e
                               15  coiiLTni-ttce-s  are  goirici    to  call  o-.i  o@er people  to  provide
                               16  testimony.    And  it  is  perfectli.v  possible  that  if  they  liz,@ve
                               17  no L&I  already,  they  iii,-,@y  ac--,k                             tl-ii@l  corimiittee  to  tcstLfy
                               18  regarding  their  recontmeiie,.ak-ion  on  Regional  1,I@diczil.  Prog2:@jlis.
                               19                    l@hile  all  that  is  going  on,  of  coue,.-:;e,  there  are
                               20  appropriatici,.  acts.    IIL@  ha-,,o-  had                                   before  both  the
                               21  liouse  and  the  Senate  App@.,opri'.atioii    Subco,,mi-i.ttees.    They  have
                               22  made  c@veill  effort  this  yea):  to  co7,tplete  the  appropriations
                               23  actions  pri.or  to  Jiai-ie.    I  don't                            where               Spnate  r--.-tZ)..nds
                               24  at  this  point,  but  the  I-louce  li@-s  completed  its  actions.

    Ace-Fedefal Rcpottefs,  Inc.
                               25  I-,That  now  is  necessary  is  for  the                             chambers  separately  to
                                   I




                                                                                 7



                  Ire@).ch an          o,-i whF..t thc!,y b@-lic,,ve the
                  2shoulclY,3 to get tl.-icD@c7!  the  I'Aotise and. t-l-io Senate, then

                  3to -re(,-orici2.e Einy
                  4          The request on the part of fhe Administrat-'@-on for
                  5RIIP viast cis I thin)-. we liav-o already, indicated at the last
                  6meeting, one which would         tlic,@ Regional       Programs
                  7to mainta4.n their p%-csent level of grant sLLPort %.ihiclx is
                  8in the general range of c-,boiit $108 million.  They  indicated
                  9durirg the te5tiniorty before bc)t-li cha.-ii-b@,rs t-.hat -&.ere v.,ould be
                  10 no special funds set aside in the coming fiscal yea@- for
                  11 Iicalth in--iritr-,nEti-;ce orgai-tiza-Lions out of the M4P budoct and
                  12  ma-"'o it qu;-te plat-r4  c@      1-iscd this     for
                  13 werc@ all that they had expected to use out of the RlfiP

                  14 appropriations.
                  15          They also indicated thct' i-lic construction funds whi&,
                  16 we i.@i).l tal.k abou,-- in a mortiei-it :Cor a cancer facility oiic,-
                  171 time funds in the r-,c-gioiiil 1,1@dical Progr@ims.  P,,,-id there %,.Tould
                  1
                  18@ be no fui-,-Ihcr i-c-quef,,t for coi-i@truc,-tion fiLnds.  They prefc-,r to
                  i
                  Igi )-,cop those under othe-- kinds of adriiiiic@trative EtuthoritiL--.s,
                  I      . Ily lii-II-Durton.  21.nd I would      some und--,-
                  20 especia
                  21 cm-ic--er authority and possibly soiii-3 -Li),i(Icr the educational
                  22 institution support programs in i-Jie NIII.
                              Therc,. @,ias an -i.nd,;_c@)lcioii al.so by the AdTIinistr@l;@on
                  23i
                  24 that they wz,.n,i@-@d to  tho level of support for ezitercjcncy

  Ace  -Fedeial  Repoiters,  Inc.
                  25 raedical ser%rices from tl-ic-     $8 i-aillion to $15 million in







                     the        fiscal. yc-ztr and that  tlii.,,      bc @@ll

                  2
                     be rcqi)r-tsted for special                              whicl-i I  will

                  3
                     refer to again in f,-i

                  4
                                 There x,,las no rez,lll discusE-,,@.on of

                  5  Education Cen@--e-@r concept d,,ii"ing the                   de!4,b@,ration.@-,

                  6  but we will talk e).bout t-hctt in a            also.  So that I %,@ould

                  7  anticipate  soi-oa  final  action  on  ou r appropriation le%@el in
                  8  the relatively near fiiturc;: %%,,hicl-i iTteciis on-- N@,ould guess by

                  9  midsurrcir@er which is far bett,@.- tl,.aii i-7c had been doix-ig el,;-i-ixig

                 10  the past several years.
                 11              N@i, there is a @@7ord of  %qarniiig  on  that.  Alt:hot,.gh

                 12  the appropriations action v.,z,.s completed la.@7,L ycz-,.r by AlLici,.,,,'t'

                 13  there was no fi.nv,),                 of ftitids until        into   the

                 14  well, it @@7asn't-i-@ntil after the beginning of tl-ic- nc,,@l,t fl-E;ca
                 15  year.  So completing appropriations action in Congress is not
                 16  enough to assurc- us that we will Icno-,,i our zictuzil 'Level of

                 17  funding. And as you will b;,i hearing, this li,-is  p,--oc',Lice-d  some

                 18  specific              for us (lu):i.iig thc@ present fiE-:ca.1 year.

                 19              l@oliq" I have got sc!vL-ril        itaiT@.3, buL- if
                 20  are some questions z,@out tliz-@tt pc-.,rhal.-,s I shou:Ld stop.  That is
                 21  really fairly riecha'nical up to this point.

                 22              D R.  1.14'. IYER:  Harold, would you tr-ansli-t-k--e the

                 23  tions  into  dollars  for   WiP   grants?

                 24              DR. 14ARGULIES:  I,.riiat has happened this year is i-lialt--

  (%ce- Federal Reportets, Inc.
                 25  with the finzLI resolution of carryover and so forth,, we c!ndc@d






                                                                                             9


                    1                   .3 Millic,@-L fO:c 1'1'!P                    d
                                                                                              4
                      up at  @out   @98
                    2 iqhai-,  anticil)iate for tire next 'Lipcal yc-@ar.

                    3             DR.
                    4             DR. SPELL.Tj7-a4: You sa-@-d the emergency roedical
                    5 services grant funds arc being i.nc,--cz7tsed to $10 rrdl,].irr@?
                    6             DR. I,I-kRGUAT-IES: The c-.,morcTency ipr-,dicFl fi-n-ids -re goil@g
                    7 to be increased froya the @3 million of this year to $15 r,4-llicn
                    8 next year, but that gets a little bit i,-,o.,cc- uncertain
                    9 during the disci,.ssions of budgetary process, since that money i-z
                    10 being            not as an l@iP c..ctivity, but rather as a
                    11 I-IISI!IIA-wicle activity in ULe curi.-ci-it7 fiscv,)- ye,3r and probably wil@@,
                    12  be next fiscal year, it will very @'Lilely drop out of our
                      I,)udget and bcccytle a sepa.,.cat-c, itcm. So it Niill riot be
                    13                                                                        , c@

                    14 as a pa--t of the R:,iP budc-c.
                                                    .j t, but this will not affect the
                    15ibasic level of grant support for l@iPs which i,!iil remain at leaskL,,'
                    16 constant. This is on the as,,:;uinption i-hr,.t  the.  Adt@iinistrt-'I-i,on
                    17 recorr@-,.eiida.,t--ioris P%-,- the samc@ a:z@ Coiigress'. In the past, t@ey
                    18 have net be,--n.   Congress has regularly increased the level.
                    19            DR. RESSOIYI:   To  it7het  extent  does  that  apply  to   the
                    201 current $8 million, that sarae suggestion t-hcit you just
                    21 raised @out  the  $15  million  being  1.1c,'I,'IiA  funCis  for  emergency

                    22 radical services.
                    23            DR.  DIARGULIES:     I %.Iill got to i-lialt-- in a moli@lit.
                    24 But the question that is               i,,     the c,,:Lrr(@.,@it $8 ;-(ii,llion

  Ace-Fedefal      fRepoitLrs, Inc.
                                         edical ser%ri.ces is being handled.  And 'chat is
                    25 for emergency in






                                                                                             10

                    I being rlaxiagcd as a                                     service
                    2           @,7it-h vont2:@,c.@tL; out o:r tire O'Lfice- of tl-i(;- Zid-miiiistrz@"tor.
                    3 It is not b-r@i.ng managed by the Rcg4.oiial             Pi@-ogram.
                    4            Dr.,. BrSSO'j'@: I:s IL?-IPS tli@,n no-L, c-illoca-tii-xg i-aoney

                    5 separately for EMS ac-'tivity?
                    6            DR. MP@RGULIES:     I hava that on my agenda to dil-i Clkl Ss
                    7 This is as good a time as any ii-' the--e a-@ no otl,.er questions

                    8 about that.
                    9            7-ill 5."ight, le-L's tall@ @boot the eirtergency medical

                    10 zysteiTs activities.
                    11                                  indicated in the state of the
                    12 union r.@-sodge and srLbce(:ue.,ntly      lie         to
                    13 level of i.i-ivc@c-;Icnciit in e,@,,c!-rci@-nc@y raedical -ysteni-,;, N,7as
                    14  at the saria time a dc-ci.,,.i-on    to do ti'lis in basically -L@,-,To

                    15  way,.4 in IISIIIHA.
                    16            One o:F them @-,,as to develop some major crrargenc-y
                    17 medica.1 systci-,,,is dciiionc;t-,,--ation activates i,7i-L-h the
                    18, on it being a total syr@-'@--c--m and to do this in stch, a mani-i,@,r

                      that the various eracrg@rt
                    19                             ay acL-4vities which are fairly
                    20 wietef;-,pread 4-i-i !ISMH,,It coi-ild be well coordi.iiz-.ted once poS-rit.
                                  There ic., fo--             in Nliill suicide p.-,.,-Cventioxi and
                    21
                    221crises intervention c-yc@l-rgei,,6cy activities, natern@il and child
                    23 iheal.th services, general pediz@-Lric and poi-,-,on control cp-ntors.
                      I
                    24 Tlier(-, is a Di-vision o@, Ern--rgency Medice.1 Services in lislill7-,,

   Ace-Fedetal      Reportcrs, Inc.
                    25letc., a whole range of emergency activities.  In order to b-@ing







                                               of th(@@,c'          and to Produce sorae

                                                                  -@ed x,; a con r z,, 1
                             er
                              ,,,D,
                   2        d   11

                                                            RC-( icnL@l
                   3  0,002:dilla-til'u, cJrOtIP  %,IIL

                   4  paid I sit on the goll-@
                                             ,ral (j3:oup    on the small (--Xecuti\fe.
                   5  body v;liich decides the basic iranag,@rrent and coitr--act processes

                   6  for  these  activities,,
                   7            The determination, then., i;7cis that there should b--
                   8  in this fi.scal year five major demonstration -icti.v,.ties -v7h,-ch
                   9  would be funded by contract--.  r@aid these contracts were
                   10 in a request for a proposal which           out som-cti.ric ago illz-,,4-ch
                   11 had an initial deadline of April 15, then extended to Ap):i-l 21.i
                   12 So that all o:E 'i--Iie              rio-,.v in z;.nei ar(-- under
                   13 Tkiat is a discrete sepai-alc-(-, activity.
                   14            I would assume that next fiscal ye@@ir, if there is
                   15 axio'@bor $15 million added to the funds avail,--blg that it @%,ould
                   16 be carried out in essentially this fashion, but @e.,ould allow
                   17 us to also @"t the same time, establish a rc@nt,--alizcd da-t-a
                   18 gathering and evaluation --ctivity which the initial inv@strr,.-Zrl"t--
                   19 is probably only going to g-tt started rather than fully

                   20 devel.op.
                                                                                       X4 St@-(
                   21            @6 the same jl--ir:ier it was felt that all of the e
                   221 emergency activities in IUIP and in the other procrairs should
                   23 be continued, but in such E,@ v7,--iy that they       consistcnl-- with
                   24 -@nd whenever convenient stipplarL,.cntary to the major contract
   Ace-FedeTal Repottc-is,  Inc. demonstration progr,-zns so that- we did in RI@IP,, to mc-J-.e sure
                   25




                                                                                        12



                   I  th at these deyr3iistrz'.tio".@, did not @,-imply b@
                   2  w h  no c- -4 Lect, which is too ofi:cii the care, initiitc- and
                   3  encourage the                of eire,,-gency mad-,'%.cal activities
                   4  to thc-- M,,!Ps as a         grarit Declivity c-2.ig.i.ble for
                   5  supploin--xi@-ary'g,,,z@nt award.  Arid w-c h@ive do,@:i-@ that. And so @he
                   6  Regional ,@ledicetl P:cograms hi-ive r(-,coi.ved and are responding
                   7  to a description of a well-coo@dinzttccl to'czil    cm--rgcilcy T,,,,--,Iical
                   8  service to be suppvrLed by granted; i-,,ilich is ccy-,tplem,-ntc-z.Llj' to
                   9  tl,.e contract-activi'z-.y.  And in fact, we exchange day to day.
                   10 data bet%qeen viihat Ni@c are doing in g),@-iits and what we are doing
                   11 in contr@.cts iqitli the hope that @,ihc@i-x the whole thing ha-@ been
                   12 co-rrj3-etc-d, 'we ,7ii.1 have a" to,-al )Docly of        and of
                 .13  action i,,;hi-@ilt is         ix-k order t-o ca@rry ou-@k-- -Ic-h@at ciiercj.-.-@ricy
                   14 medical activity.  I-,.s I thin]; you         we have set up a
                   15i separat(-'                body %@,,hich i.-- going to look at
                   161respujiE;cs to our invitation to  submit supple)-,.cnta).-y o,,.,ctuik6l

                   17 requests,
                   181           DR. 1,9-@YER:  Tliiv, is i,@ithin @%IP?
                   19            DR.  ivJ@RGULIES:  This is wi-uiin Prlp.
                   20            DR. 1.1,'i,YER:  And          from the co,-,%tract?
                   21            DR. I'IARGULIES:  011).i-@e distinct and separate from the
                   22 contrz.,,ct.  The contract activity is aK,.other i,-!7,uc- entirely.
                   23            In order to give enough           to the IU@'@ps to
                   24 rcspond and to develop something N@yhi,ch.is mc.@ctyii-ncjful, we have

  Ace-Federal f@epoiters,  Inc.
                   25 given them a fairly tight, but reasoriz@.bly broad pc--riod of time








                    I  in @..?hich to                                                     arc,
                    2  z-@t the prc@s@-.,r,,L t-.imc, i,411. in. Thc-@.,y reach a fai@1-y formidable
                    3          and IL-hc!y will ha@7@e to  bc,.            on May 15c,
                    4                    we        don(-,-r iii order -to sc-,t LTp an effective-.
                    5  review mechanism for a kind of special action, was to ask
                    6  Dr.  Besson,  Dr.  TooriAey,  Dr.  Scherlis,  i@?ho  will   act   as
                    7  chairman from the zcvi-c-@,e- corcani-ttce, Dr. 11ciPliod'rz:@ii and Dr. r@oth
                    8  from the Cov.-nci.1 to i.,ci; tog "chr--,r for  tl).ese  two  bodies and for
                    9  the Ytt,/;.PS in making a          of the r,..r.-@rcjeiicy l@-@3dical
                    10 Systeris grants rc-.qtiests,                 occurs, we will give
                    11 Lliei-a      in'Loi-i-nati-on           the status of the cort@-a--,L-
                    12 nroposzils so           is rio confirmation                 i-wo.  Ar).O@

                    13
                       will try to          thr-,m    discret(:, as
                    14              We would anticipate that the ET@-rgency Medical
                    15 Systarris activitic@s wouicl, con-cii-iia beyond this year.  We have
                    16 not s(--t aside i)@ spLcifi,c sum for that pu@-pose, find I will get
                    17 into the funding aspects a little bit later.   But you might
                    18 iyant to ask further  questions about the Emergency I,,Ied@,-cal

                    19
                    20              DR. SPELLI-9@N:   When you say that the grant awards

                    21  will complement --
                    22              DR.           1,1.@tch, could you use the spectIr.er?
                    23              DR.                 My qnc@rtion is in iii,@ring one of the

                    24 qualifications  f graiit a%qa"ds for
                                          0

  %cc-Fedeial Repoitefs, Inc.
                    25 projects ftmded by lIdiPS, dot!<, -IL-.his Tean tl-ion that the. grant






                      aN,7zirds are. i.n     -urP:Lem@l,-, t:s of           or doc-,s -Llic
                    2 complemeiit-,,ry p:cocesl's occur iii a @ky@iy ill @..,hich. the
                    3 and gr,)-rit       are,, two di.@-Ic-roxit        d4

                    4 institutions or entities?
                    5            DR.  MARGULIES:  It is complcmentzxry in a conceptual
                    6 sense.  V7hai: we are s@-ying is we don't went to develop
                    7 contract  activity  which  would  represent  a  totzs"-  approach   to
                    8 a system and have some grant awards \,@,I-iich have a piece of
                    9 equ5.pment here and training progyara there. I-Ze  wE.,.@,it  both  of
                    101 -them to represent an c-.ffect.i%rr-- approach to orgar,-izing a to-tal
                    11 emer-goncy system.  But with the PdvIP activit4-os, I think Nqe
                               e la-Crality W114c-h ma.1, no-- b@       of tyke coi-itrc@ci.:.-,
                    121 110-vO sci-ft
                    13 because %.;e are dealirig with Li           1,1(@,.dicol Progra..m in

                    14 case,
                    15           Being very specific, if a contrac-l'-- is
                    16 contract -'%-.his    is            fa.- an             1,@'C-.clic-al System
                    17 to a unit of government in a community, it             bc@  with  the
                    18 Linde@:sAL-.anding that thi-s is a very ti.me-lirnit-.ed and emergency-
                    19 related activity.  It has to do with the moment at which an.
                    20 emergency is identified until the Point of                    of
                    21 you do viith ihaL-1 emergency in the emergency room or whatev,@!r.
                    22 And beyond that, the contract activity, doesn't appl.y.
                    23           it doesn't, for               go to in-lios,,Dita.L
                    24 emergencies, to referral activities.        It has to be tliz:it

  Ace-Federal       R(,poticts, Inc
                      discrete.
                    25i







                                                           in the lZcgion,,-,i Medicl-l

                   2               this         moi.-C. tl-i@..n z,,n E,' S carryolz,L ef'ecti@ c---!Y,

                   3 bu@@ in a6,J3.tioxi to              E@,oriietliirig which ha,,-Y, an
                   4 iii:[lL)c-ncc on the      of @,jha.c.     Rllr- does  and  on  the  re@st  of
                   5 the systcm @,@hich is around  it  such  as  the  other  L-.i-,bulc,.to,%-y
                   6 care,  the  referral  sex-vices.  And,   of   course,   with   our   spc-,c-Lal
                   7 interests in heart disease and in strokc-, we x,7ould be
                   8 particularly               to how effectively they include cc,.rrip,--te,:,l
                   9 to deal iqith acute infections, acute strokes and so on.
                   10            DR.           Two               Harold.   Oiic-, is you z-t--e
                   11 l,talking nc,@.@,.t year in torus of     move. from $8 to  .$15     million
                   12 of the c           being theme to           to d.,.air(>lop c:ent;:&.Ii 7-cd
                   1 3information.    Is it the iii-cont to cxl)encl. on t-lioso-  original
                   14 five contracts, to  e7,:tend  it  to  more  or  to  expand  on  those
                   15 original five?  What 5.s the in-Lent     in terms of next
                   16            DR.  MARGULTES:  It is to e@:pand it to more new
                   17@ contracts, I aiii qu@.to su):(--, b;,-@cause I be'-ieve i@,hz-,t we will do
                   181 -- and -'c-liis ec--.T?c-nds in part on 'clic deinarid -- I jusi-- loo3,:c@cl at
                   Ig some of the contract  repoi:tt.,,  subraissiaiis,  yestc-,@da@  --  is
                   201contract in such a away  that  w3  obligate  funds  i,@',ii.ch  will  carry
                   211 them over -c-lie full. pEriod of      th@-,,c--year coi-it;.-,ict so that
                   22 @they @;ill- be full fundc@d Contracts and the ones v7.',iich we
                   23@ would be )-oolcirig a,'L- in the xicx-t round, therefore,  would  be
                   241 new contracts.

  Ace-Fedetal Repoiters, Inc.
                   25            DR. 14AYER:  Jerry.





                                                                                     16


                   I            DII. P@ESSON.-  Ma@, e I c 11       qlzcsticii in a
                   2 d-i.f      v,ay. Ho@-7 yrtl,)CII              znticip@.,,-e would be
                                                    c, -v.7otild yo


                   3 allo@,?ed for thE-, five
                   4            DR. IIARGU,@'@7ES-. The fi%f-c co,.-it)cacts will for the most

                   5 part-. ccnsunie -Lhc, $8 m3..Ilion.
                   6            DR. L:'FSSON: Tlicii, the irioneys pertinent for R-T-,IPS-EiliS

                   7 are outside of any-thing in

                   8            DR. 1,11@RGULIES:  Yost they are separate.
                   9            DR. BESSOI@,': Pmd the  only  reason  they  are  not  being
                   10, conside;:cd by this commit,--ea is ):)ecause of the lateness of

                   11 submi.,3sio.-i of the grant pT-@oposals.
                   12           DR.                  h@.ve tli e same  problem  with  thoL,-e
                   13 and with the co-nniQnity education &(-,tivitics which I can a@t to

                   14 in a n,,.omen't-- also.
                   15           DR. BESSON:    You previou sly have spol@.en of PI-@IPS
                   16 it-,oncy ar, F@-,aybe rot b-cing allocated, but sor@.ow'Lizit seqi-,@c'@:-,tcred
                   171 for kidney actiN,j.ties or olc-licr activities. is there any
                   ,8 thoucht in Pj4PS about lio,,q match of the --
                   19           DR.           C@,li-i you hear him in the back?
                   20           Tl%,.ey can't hear you, Jerry.
                   21           DR. B'@7SSON: is there  any  thought  in  @IPS  as  to  how
                   22 much money would be allo'L--6L-.ed from P@.TI.PS funds for other

                     activities?
                   23
                                DR. I.V,,RGULIES: There is sorne thoi,.cjiit about it,  and
                   24
  Ace-Federal Reportefs, Inc. I will get back to that, Jerry, biit it is wrapped up in sevcral
                   251





                                                                                     17


                     things in our f4knal fundi-ic level. a-,-id the       in ol:,."

                                                  oo            but
                  21 review cYcIc- @',hici'.l iE; not i--           it is interlaced.

                  3  7@,nd I     rath,@,7--
                                         .;o ove)-- it all -;tt OrLo tilil,.I  n],   t

                  4  would be clearer.
                  5            DR. DESSC)ZI:  Well, perhaps I can indicate why I am
                  6  asking the question.    In describing the five contracts N,,,Ii-i.ch
                  7  are going to be let for  what  you  refcr  to  as  broad  systems
                  8  for rmergcnov I,!;edicLI Services contracts, the %.,,ay RMPS vTould
                  9  approach it, the implication is that we are interested in
                  10 finding out on a                  basis how to orc,             a@rhic
                                                                        .,anize  geogr
                  11 are@is for the provision of a total system.  Bu'L-- l@iPS has
                  12 ,,o-rvc-d                                              in rc-1,@,ting
                  131 to the                                in a coi-onuni-',-,\T.  7i,itd I am
                  141 wondering         it might not be a more appropriate stance for
                  15        interest in r@l-ILS, rather than fui-iO, :demoiist.)--;.ti-on
                  16 programs to fund N,,hat I might call sccdl-ings and spread i@-s
                  171moneys as       as            rather than concentrating th('@m on
                  18.1 single largc, grandiose activities.
                  19@           This is peripheral. to the review comiTiiti--ee's
                  20@ ectivitie5, but E@irioe I 'I'lave bz;,,en ii@rersed in the 60     of
                  21, reading material I received the other day, I have beco-,e very
                  22 much a@,iare of P,-?4PS's emerging role in EIIS. Arid I  wondered
                   I whether it right not be appropriate that we gi\@ consideration
                  231
                  241 to being very lenicnt in funding some of -Lll-lese 35 proposals
  Ace-Fedeiai r'%cpotters,  Inc' that are being received from the point of view of encouraging
                  25






                      I                      of                    i'-'-ici- devcl.OPTaent of 17@-IS
                      2               without nec,-c-sErily fal                the strai'7,1-tt criteria
                      3 t-h,).-c i,@c- h,-tv@- --La5.d out in the     for          rcqLle."@tr., hewi-ng
                      4  very closely to a certain set of criteria and either being very
                      5  meritorioii,- and                 having, p.@:iori-L-y or being somewhat

                      6   lower merit and thcrefo@--e being passed ov,er.
                      7              I am just wondering as to how we can,most effectively
                      8 spend  whatever  dollar-s  RI.IPS   cc)ri@;iders   tlicy   are   going   to   allo-t
                      9 to this aspect of their new activity.
                      10             DR. 14liYER:    Harold, would you care to comment on thal@-'@,,
                      11             DR.                   Well,  I don't think you need feel
                      12 bov,:,.id by the sizes t@)c             i--Iae           roou-'@r    n     ol,    h
                      13 contract activities, jer,-cy.   We would                           there      world
                      14 be   a   fair   range   of   potank-lialities   in   the   grant    requests.    And
                      15 what we z,,re really telling aL)out is the Avoidance of funds
                      16 expended for iini.focir,.l iritc-r(@-sts         tr@,ining 16 E@inbul.z,,i-ico
                      17 drivers i-7.hc-iii  there  isn't  anyth-".ng  for  '--hem  'co  drive  or  he,-i%7y
                      18 investiaents in radio cqiij.pm3i-it when tlierc-, isn't z,.iiybody at
                      19@ the other end.   That is really, what I am tal)--.ing Ebotit.
                      20              1  thii-iY,  -i.n  looking  at  requests  for   grE,,nt   awards   in
                      21 the        one merely r@cclkds to             sure there is quality or
                      22 potential   for   quality.   And   it   doesi-illc   have   -the   some   kind   of
                      23 rigidity that the detaonstr@itioii d.oc-!s.         )3ut   at   the   same   time,
                      24 we are hoping it represeii@u,,; a i-ii-@thod of polling the system

  kce-Federal Ref)orteis, Inc.
                        togethc-r rather tl-ian dealing with only            one -@ec-ent of it.   And
                      25                                                              pT








                        that is realli, (-he  cxiJy

                      2               DR.                            c@ oi-nir,-@ntf-7 an EMS?


                      3               (!lo
                      4               Vlhot would I)c,  than,  intent  next  ycar  in  tc-.i-itis  of  M.IP

                      5 acti\Fity in El-IS?
                      6               DR. I-t-ARGULIES:    I th@inl-. this is going to depend
                      7 pretty much on           total. irifluencc.  of the current round.
                      8 And there a.-e really threl-, things involved.

                      9               one is our general appropriation level.
                      10              The second is the final decision on what will be
                      11 done with    the  addiL-lion,,).l  c.,rr@.ergcnoN,  mp-dical  activities  in   the

                      12 $15
                      13              zncl. tl-.@- third       ))c-,@ soi,.ie jiidgm,-@.Vii- about lio%@; ready
                      14 ,io are to   do riore emergency activities.
                      15              1 tol(i you I thought the $15 million would go in
                      16 @that                Bill, but it really hasn't been formalized yet.
                      17 tt  is  perfectly  -sssibl(-,  the  role  of   rl,!P   in   the   EMS   --,ctikrity
                                              k,
                      18 will  be   a:,--defi-r,,cd   either   by   legislation   or   by   something   else
                      19 during  -cho  co,%iii-ig  yea--. But   assiA@-,,ing   everything   I   have   said
                        is  true,   I   would   anticipcite   we   would   continue   to   show   ct   high
                      21 level  of  iii,@-crest   in   the   support   of   Eme,-rgency   Medical   S,st@-,m
                      22 activities in the next fiscal year as wel)..
                      23              DR. 1,11,YER:    Under IUIP?

                      24              DR.I.V,@RGULIES:    Y(----
  %ce-Fedetal Repottefs,  Inc.        DR. @IAYER:      Under separate kind of review effort?
                      25




                                                                                                  2 0



                     I              DR.                          @qoiil-Ciyi' dr) it
                     2  becau-.r-- t'Al.'LS %'ILS c)- matter oir- duress.  Pit that poi.nt, @ve could

                     3  enfold it into the @egular review
                     4              DR. IIZ,,YJ',I@. I think that is an important concept for
                     5  this coimnittee because it is the bits and pieces issue..
                     6  Slowly but surely you dissect everything off.
                     7              DR. I.IARGUIIES:   lqell, let me deal with that issue noiq,
                     8              DR. 14AYER:   Before you do, let-. me malze a co,-,,.,mciit as
                     9  someone who is absolutely and irr(-.vocEbl.y Eiddicted to
                     10  nicotine that as all of you are aware, the Secreta.-cy of this
                     11 @Duperb                  ),,novm as IIEI@' has indicated a Ptpndat-o- w.rij. cli
                     12 1-i&.s c@Lie oy i do%.;-n though this.  I thi.nl-. c%,cryoj-,e -.s on
                     13 owii in relationship to whet@,,(-j,.r@ they fe,@l the liglit.,).ing , @)o-l.t
                     14 coming do@.7n from dowrttovln or not in regard to that issue.
                     15             I say that in preface to I have already niade by
                     16 decision.    I vian,- to leave tomorrow, nolt-. today.
                     17             DR. llARGULTES:  That statements i.s part of the

                     18 confidentiality of the
                     19             I think it riiighl-@ be easier for us to deal with the
                     20 budgeta--Ir issues because they hocp coming up rp-thc@r than with
                     21 such things as the            health education center concept.   lihat
                     22 has happened in this fiscal year has been the appearance of
                        a funding pa@@e-n which iii4g!it have c-,nil.3a.,cA-assed Lis badly, having
                     23
                     24 us reach the  end of the fiscal year with more inoii(--y                  we hzi@-
   Ace-Federal Reporters,  Inc' anticipated end no way to spend it or the ippearai-ice of that
                     25





                                                                                        21


                                                                  to spcn.d it as X."Cll
                   1 &,mount of- l@.olir@y wit@h us
                   2 or no add4-!,-@-onal                         iriglit @,Et Occur.
                   3           l@ow, in       rangc--- of                      is abci,,,"-
                   4 what happcx-.ed: I-le did not gc,'c. a clear r@tatc-,,i, Y@t Lsbout oull
                   5 total funds for this current fiscal Irear until after the end
                   6 of  Januai:y.  Even        we hz.-.d receiv(-@,d that information, there
                   7 v.,lp-s uncertainty &,bou4L-. the fui,,dE, which would be sp--nt for
                   8 1,1@iintenarice organizations, so-roc-- $16.2 million, and the funds
                   9 which were set   aside for l@rc.-a 11(naltl-L Ecli:tcatioii Ceiitei:s,

                   10 $7,5 million.
                   11           Furthe@iore, the $8 million @,;,I),ich had been
                   12  for                                       lic-,d not y(,@,@t- bee@,ii F,@--t

                                                                           contract
                 '13 aside as they are now as I described to you fo.7.
                   14 activities.  And so we had this range of uncertainties.
                                There was from the preceding fiscal year, you
                   15
                   16 recalJ., apprc)@,-imat(-,Iy $44.5 Ytillioii i@l-iicl-i wc-fs not  in
                   17 that fiscal year which we had been promised @.-,-ould be released
                   18 in this fiscal. year.  I@L. was released, but only in part.
                   19 So we aoL-. to about       Jr.nr-j@.17iyig that there wore several
                            I                                                                 1
                   20 possibilities which gave us a ronc,,e of difference in the      ni@ on th
                   21 of JUiie %,.,hich is tur-,-&ing out to be true of about $22.5 million

                   22 uncertainty.
                   23           Well, Wi4-1  $22.5 i-Liillion unccrtEinty and the
                     (7tesi.re to be able @-o iise it  effectively, you have to dev(@loo
                   24
  Ace-f'ederal Repoitefs,  Inc. some footxqor)-..  And so we developed some footx,.,orl@o This
                   25





                                                                                                           22




                                                                                         di. c E,, I
                          included the 6@cision to -support Emcrgcnc,.@                          I; v c;, t c--, m s
                     2   doci.dad on rath(-,r l@,to              it I)eczi,-iie cl.(,-ay.- ho@..,     other
                     3   EIIS activities @.7ould be-, that              %,7()uld   decade   educatiol'IE-.l
                     4   activities which @qere                  but no,i-- the !;arro- as,  E,,.n l@c!a
                     5    Health Educat@'A.on Center v,Tiiich had to be clc@c@ided l@,te for otl,,er
                     6    reasons which I will get bacl"- to,  Hand we would at the same
                     7    time   to   co%rer   our    potentialities    decide    now    to,c-harige    the
                     8    review   cycle   from   4   to   3   a   year.   That    became    the    pivotal
                     9    point in the  whole bi-ldc,,et      ar3r   romance   becEiu@,e   -what   we   had    to
                     10   do was to rtial-.c-, a decisio-,i to go from 4 to 3 a year,  thereby
                     11   -change -.PiFcal yearst  and @L-herc-by give. us the opportunity to

                                                   i-i f-scaL  172 or 173 acco
                     12   use- ;.u,-iOs          J.    .1.                           r(li.ng to v.,hFt we
                     13   had                emd   in   ',--he   process   of   doing   that   anticipate   tIl.e
                     14   level  of   coTm-4.tarent   for   'Liscal   173   and   174   so   we   didn't   ov,er-

                     15   ex-t-lend ourselves.
                     16                Added to that was the Uncertainty of                             tha FI@I&O
                     17   funds would actuall.y be to@Lally used.   And as                        goes on,  it
                     181  c,.Pi)ears to me p-@rsoi-iaily more and ictore likely tli.at they will
                     191  not be to-r-cilly used.        So tl-i.@F, @..dds some                        funds
                     201  to the P:@--Ogr'a_ml
                     21                 1-@hile all 'ch-.s         @lo,.tng  on,  @.--  $7.5  million  i,.,li4.ch
                     22   had been    --ct aside for Area Health Education Ccitors v;cis
                     23   kept   bac,',:   and   remains   IDacl,:.   So   we   still   have   the    uncertainty
                     241  of whether we will, have av,-,ilz.,ble $7.5 million for educational
   Ar-e-Fedetal Repoftefs, Inc.
                     25   activities, whether some of the IIMO money v7ill be returned to u





                                                                                                    2


                      I ar&d whether wc@ wil-."         fu,-i@is availi,.blc n-t vzi3:yi.ng level,..;,
                      2 d@pendi@ng uprjxi the grant                 frorti the Regi-oiial  Medi-cz,.l

                      3 Progra-ros in fiscal 172.
                      4             VThat  we  decided  on  is  a  "-@thl-@r  simple  rlarieuver   to
                      5 give ourselves maxirourti flc,,.@.ib4.lity.   And the way it is go4-ng to
                      6 work out,       will  be  able  to  e@,p@@rLd  all  our   funds   no   matter
                      7 v7hat the decisions             I-le c>,.te-ncled the fiscal years of each
                      8 of the prog,.-arcts in this review cycle, but @,7e did not give
                      9 them gran-c. awards to coNter the whole pc@riod of time.              So   if
                      10 on ll!'P we.-it      12 months to 16 morths, the  grant aucird Ni7,e,-s
                      11 -fol-@ 12 monL--h.-,.   And what Nie told thc-.@m was,  "Show us i,7h&,-. your
                      12               z@rc- for ,4L:he full 1-6 ii-ioa-itlia. find if y-ou  requ3.re
                      13 X level, you can bo assured of gcttix-tg thac if that@ is aii-
                      14 appropriate   level.   But   we   can   decide   with   you   iihetlier   you
                      15 need it this fiscal year or next f         4@scal   year."   That   mean'i-- t'.iat,

                      16 in the majority of I--h(-- procr@-.m
                      17             DR. l@IAYERt   In terms of     release, Harold.'
                      18             DR. 1,17@RC-IILIES-. In terms of release, yes.-
                      19             It covers the saiae period of time, but this
                      20 that up to i   ,tne 30, we  h@.d  a  liebilui.t.y  just  in  grant  a%,,,ard
                      21 for basic R,,,!Ps of sometliii-ig 3.ii the r@.inge of $8 million i@,hicILI
                      22 could go in one fiscal year or the other and produce the same
                      23 result.   This is the only ye@,r                  ever be able to do that,
                      24 but -it is also the yo@@lr in @,@hich the tincertitiil-ies app-c,.a-r to

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




                                                                                   24



                              That la@c;t            do,.-i"c belicv,a that for ii

                  2 but the flexibility is


                  3
                  4           So we are really trying to play           varying kinds

                  5 of games.
                  6           If you say in       middle of that, "E.,cactly how much
                  7 is it @,@u are going to home for Ell@IS and how much for educational,
                  8               I can just add to the, fringe of interest by
                  9 telling you abou-L. what we are thinking about.  lie hope that
                  10 can     in the educational activities in ti)-c general ranae
                  11 -of abou-'L-l $3 million.  And in thc@  we have had a greater
                  12 lc;v(!l of            bc-car!,,,;e. It has be@-.q    l@,vrd to
                  13 predict      might zictu:tll-,, core in,  But I i-7oiild not be
                                                A
                  14 surprised to see us workii-ig in the some general range for the

                  15 Emergency Iledical Systews.
                  16          Now, this depends o.). t@ zic-Lioi-i v.,hich may ba tal:4kng
                  17 place today, I am not sure.   Part of it do-@s.  Ai-id threat is than-.
                  18@ we have gone through, and T- will licivc- to comL)3.0.,te tl-LiE-,, B."Lll
                  19 I am sorry that this gets cc-nplex, but, de.-Tai it, all of it is
                  20 complex-  It has been like that.  V7e ha,\?,e gone through iii
                  21 interesting tayigo -- you can't -'Panama with four
                  22 we have gone through an interesting square dance on tlic- 7@ea
                  23 I'Lealt-h Education Center activity trying to decide who doas
                                                                                  t4 <)-
                  24 what. And it has at lez-,st reached EL point of some d(,@f@'-n3, . ,I.
  Ace-Fcdeial Reportefs,  Inc. And that is that in the opinion of - a office of        nd
                  25                                      t-h                         a





                                                                                             2 5


                   I  budget and of the Of'Li-co of th- S(@cret:aryr                    called

                   2  @tii A@,,7(@a lIez-,,Itli j,duczxt.",.o,-i Cr--Yitc,,r is rel@-ttcd to than

                   3  Coii),,,,tission iiioa,,@l which i!3 essentially an activity conduc,cocl
                   4  primarily under the au,---pLcos of  z,,  t)nivcrsit.v  health  scicn,@@e
                   5  center with thc.,, 7@rea@ IleE,-".th ECucat@.on  Ceiiter  a  satellite

                   6  thereof.  Paid  this  with  some  eral)allishmeiits  is  the   concep,-,

                   7             The essential ingredient is the Extension of the
                   8  energies F@iid i-r,@,'L,-.crcsts of the i,,nixycrsicy health science
                   9  center.  That  is  not  exactly  iihat  the  Carnegie   CoirLmissio-r,

                   10 said.   It has Lecome the general cot-icel@t in the JAIL@ ei-td 1-:1-ic

                   11 -article by Margare'L,-. Gordon and in the Office of the
                   12  C!@:,3 ai-,Id I          Office of t'k,,@ Sccretary fc--,el tl,la-'%' t",Iat

                   13 is fit for Hill ilur(-@,au of rdi3c@.tioi P-,r,.d i,laiil)o-@ier Trailil-'..,.Ig to do,

                   14 not fol-- IISI,I.IIA r@@',P.
                   15             There was in the middle of this discussion of Area
                   16 health Edticatic)rt               in among  other  places  wli@,.t  is
                   17 knoi@in as the blue sheet a statement which said -'chat
                   18 Counsel opinion d,%-lctcid )@,,IP f@rom c@ducEi-L-ion@,,l activities. That

                                         rt'her-c-, ha--,I bc@r--n at -L-.i.m3 no GP-yier-z,-,l Coti,-,i,;c-l
                   19 was in error.
                   20 opinion               to en,.rl.-@lody.  The-,--e had bc-cii some gi:arl,--s which
                                                  .9

                   21 were incomplete @,ind  which  Nic-  asl,,cd  them  to  comolate  et  a

                      later date.
                   22
                   23             The C-c-nc-ral Coiiiisel opinion on (-@dticat,-onal z@ctivitics
                   24  for P,!d,P is quite clear-ciat.   It sa-s that u.rd,.ar 92.0(c), we

  @ce-Fedetal Repoficis,  Inc.
                   25 can i,nc3.ec-d concitict educzxl-i.on@,l activities which need )iot.  be





                                                                                          2


                   I conf-iic-d. to tl--c-.:                    conc,@l-@.,C-d with
                   2 Ui e"tiliz@i@tioll@ of                                          b-Li
                   3 added the cormicnt- that -chcy J-elt cl,c,--,r- that-, Ylt.-IIP not IDL,
                   4 involved throucT)-i 910(c) in the supp-,)rt of tr@iining Z'4ctivities
                   5 which ec-.senti ).Iy cltang@cl the             into Skilled.
                   6            And to be definite about it, they said such as
                   7 training a high school graduate to be an R14, )?@,yi.iig for tll@@IL--
                   8 or paying for the stipends or facul-cy for r-@,,adical stizdc-xits and
                   9 so on, ayLd that      were. concerned         the community activity
                   10 which linked              to service.  And the-,, are quite co.-,.i-

                   11 for-'c-&-ble %,iith that diffc-)@cyik-liatilon,
                                 8incc,,, tl,.al-@ i-7       tl-i,, pol4-cy      w'-iich r-..!@IP
                   12
                   .13 h,),s been          for so,YnL- time ziri(-l cetisc,,s us no concerti
                   1 4           DR. IIAYEI@:  Since the ]:)c--g-'@nning, I-lax:old.  CC and I
                   15 wrote tt.@or@e exa,.ct st-"m-, qui-d--,Iine,- f4-ve yea:cs ago.
                   16            DR. I-IFiRGTjLIES-. This is  buttressed, then, by the
                   17 Generzil Counsel. opinion, so we have no problems over it.
                   18@ So wh,7-t @,,L- had done witl-,oi,,,t any of these decisions havixig been
                   19 made and without any G,---no-ral Counsel opinion is to run the r4-s)@l
                   20 of circulat4&ng to the Rcgio.,ial l@r--di.cal Programf-, the d(@@scription
                   21 O.L a prog,--zxil co-,)j-iunity based education activity to which %ic
                   22 invited their attention ar,.cl for wl-ii.ch -vie Zara going to provide
                   23 supplerentaj--y grant awards.    This is parallel to the Ei-ti--rgency

                   24 14edical s,,sterq activity.

  Ace-Federal      Reporters, Inc.
                   25            lie could not put this out with any term.that said






                                                                                                                                                                 2



                                                                                                                       c, not OvOll Silre at

                                   2  that  pc)-'nt  anyone  would  allo@q  us  to                              do  it  because
                                   3  draft  op-...-Lioii  N-7e-s                             Erotird.          But  F,.,-iy@qay,  i@.,e  did  it.
                                   4  And  this  meant  i,.,e  had  to  wzz,.it  uiiL@il                        t@c  last  minute,  hoping  to
                                   5                                                            golc,  no  clz.,rificr,,tion  so  we  went:
                                      get  some  clarification.

                                   6
                                      ahead  and  circulated  th@-,ouc,-I-tout  thc-  coLini--ry  a  description  of  wh
                                   7  we  meant  by  some  kind  of  a  coiflmtinity-based  educational  and
                                   8  service  consortium.    This  has  led  to  a  careful  review  by  the

                                   9

                                   10                     Ikle  do  ro%,i  have  in  hc-tricl  @a  iiuab.,---r  of  submissions  for
                                   11 'gra-nt                        They  \,7ill  be.  rcivic@@.Ired  on  Mcly  20  to  21  becEtz,-;e

                                   12
                                   @  some  of  tlie'ia  a@                           com-'@rg  ii                   I:)c)tli                            r,,id
                                   131          1-1c@E@lth  Education                                   And  t@e  ones  involved  in  tlia-'L-
                                   14 review  process  wlii.ch  will  bc,  carried  out  at  the  same  time  as
                                   15 the  Allic-d  I'Lealth  Confarer-ice  fro-,II  the  review  committee  %Still  be
                                   16 ililton,  @.ndarc"on,  Ec@r,   and  Hess,  with  Pari-y  as  chairm;--n,
                                   17 and  from  '"-lie  Cc.)tinc5.,l  Torty                                   tied  Bob  Ogdczn.    And                       hz@@.,c
                                   18, asked  Al  Popraa  formerly  oi,,  the  Coi-,n.ail,   former  I",IIAP  coordinr;itor,
                                   19 to  join  the  group  ro  that  %,:e                                   bo  t@aking  @4  review  acti-ovi
                                   20 en  bloc  on  the@;e  educational  activities  at  i-bat  i@;ime.
                                   21                      The7.-e  was  jrstno                                    by  v:hich  we  could  conduct
                                   22 this  order  an  orderly  rovs.ew  process.     And  as  one  more  f(@atti,-e
                                   23 to  it,   it  i--  likely                                                     stop  at  this  point  Lc-,cau,-:-e
                                   24 the  additional  feature  gets  complicated.    The  --(;-st  of  it  has  b--@@

    Ace - Fedetal  Repotters,  life.
                                   25 easy,





                                                                                2 a




                              Leonard.

                2             DR.            Hove you distribut-.c,@,.d to th@

                   of this coremittca the sait@a-           you Pont-. out to the
                4  various regions as far as their copi.@.l.-Ig 3-n foi: EL@IS or tli@s-@

                5  educational ceritc;.@,-,?

                6             DR. 1,M- P.,GULIES: Yes.

                7             DR.            V-7,@s had th?@,L-?

                8             DR. I.L7iYj-'.R;  No.
                9             DR.  I,.IARGULIES: Didrift this go to review COITLmi.k@-tee?
                10            I am SOKXYF it should have gone to review committee.
                11 -I thought it went to revic,,i conunittce- end Co,@ircil. Tlipt i-ias

                12  an error ci-i ou@.- pc.::t, than.
                13            DR. SCIIERLIS: Per@izT3s we can hE-xve those.
                14            DR. MI.RGULIES:  We cari get them to you today.

                15            DR. SCIIFIZT@IS: Fi,n@,.
                16            DR. IVi.IIGUZ,'-rES: Lc@t me add one mox,,e, feature to it
                17 which giv,!.s you an idea of som-@, of th@- special procedures we
                181 have to ce,.r-ry ou6-- rcga):ding tl-lcse t-%,@,o categories of interest,
                19 the Arc,@, Education Se;--vice one and the EIIS. If @.ia get funds
                201 relc-ztE-,ed yet this fiscal    and I think it 4-,- likc-ly, which
                21 the Office of              and Budgc-!Ic does not int(-,.nd to hAve
                221in continuing appi@-or,,riz,.tion@,, we will have to nrovide evidence
                23 that that ironey c@.--a be spent to support activiL-Ii.as in
                24 without raising the level cf-              to in(3ividuAl p,%--,)grairs.
  Ace - Fedei3l Reporteis, Inc. Now, that can be done. It can be dozie if we handle
                25,




                                                                                                                   2



                         I for         choice tile ):,!,RS actj-Nrity a@@, e, di,.',Cr@,tc-@ E@,ctivii--y in  a
                         2 Prot            If        prog'4,1-cin         in @)nd spys              1-i@4ve e, well
                                                                                  -i.1cy, it will t@,,I@c-
                         3 kni;-_        qc-ncy Ij,-@dhcal Systcni activiL.
                         4 years to coR,,plete,  it                 cost X e,,-irioi@,nt of  money,  "  we  c,-.-  n
                         5 a@.7zx,d   a   grant   based   upoi-i   'clic-ir   total   needs   for   three    yez,,rs
                         0 and   reach    an    agreement    for    them    to    carry    that    as    a    separate
                         7 item in their budgc-,.-.   At the end of those thx:ae years,  that
                         I
                         8  'Ctiv-'@ty N.:ill' havr-@ been complc@,ted end @,7ill
                           a                                                                not be part o4

                         9 their basic commitment.

                         10                I think that the Offi@ce of ilai-ieget,.icnt Card Budgct @qill

                         11 accept -Beat procedure.

                         12                DR.              Vlith t'Alle                                  for  'I--hr@

                         13 three years coming out of --  ).c-t iAs                          $3 riillioli

                         14 original      $3       million.

                         15                DR.  MARGULT@',S:       That's ric,-Iit.       It     is     ersential-lv

                         16 fon..,ard funding for the line item ii, tli,-.ir own budget.
                         17                DR.      MAYFR:   In o-',--hc-r word@;,,  the, corrLmit,,iic@nt that iiotild'

                         18 be   made,    let    us    say.

                         19                DR.                     I-.-,c- would release all t-he fund@-
                         20                DR.     14AYER:   There would be only a                         dol@.ars of

                         21 1 c..nnt-ializc--@d              that would be inside at tlii,c-  tire,  if, that

                         22   @,ihat   you   are   saying?
                         23                DR.  @l"%RGIJLIES:      Yes,  we would relers(-- tile $3 million,

                         24 1 but at- th,-, el-id of th,--,t pox,i.od@

   Nce-Fedoial Reportefs,  Inc.
                         25                DR.  l,'L%Y.ER;   It   v!ould   be   spread    over    tlirc@.e    ye@rs.





                                                                           30




                                                                       th
              I            DR. IIARGTJLIES:  it 1,;oulcl be   out
                         If the                                y hii-pdle it
                                  -re syla,,7,f ?.I,(,ay would j)-@
              2  years.       _@y ,go     4-
              3  through some kind of a (,-ont.Cact 'CO )4.eeP         At the
              4  end of @ tliy:eo- ye,-.rs, t.1-Lei.r     1-c@\rel would be wh,-itcve@,@,
              5  it liAd reached at that t-  e>,clus.'@..-,re of t' F@t-. $3 million -li

              6  then disappeared.
              7            DR. SPELLI-IT@N: You wo,,).Id make the,, th2.-ec--year a@,:ard

              8   at one title, one sum?
              9            DR. 1,@IP,.RGULIES: To got the funds obligated-,,,
              10           DR.            OI@IB @,7i!l commill, thcm?
              11           DR. MARGULIES:  I,,Ie don't I,.now yet. That is our plan.

              12                             is
              13           DR. I gi Pr@ U,-" 1 1, SIt is not so extraord4-narv.
              14           DR. I-VIYER:  They have becn do.@.ng that in construction

              15 for  years.
              16           DP,.            The roF,@-c-n theNr have- to do that is
              17  because they are          to               L-'un("Ar,,,. It @s
              181 their -- their being div@.1-ntown, @@ihoover is downtown, it i,--@ aliiayL-1t
              19  they, all those peopl,c- downtown vlith r.-sponF;,@ility -- so the
              20  fund was not released, and they have to &ev.i.se a method of
              21  releasing it @id making ijt-. ez'focti.ve. I think -'c-h,-,y had

                                              position  to  r
                  assumed we would not be in a             (--@ci-)ond as effectively
              22                                                               &
              23  as we can.  P@d. we can do i-L. becaLl.,7je we @,;ill 1-izvc- reviewed
              24  and approv-ed and identified actions on that ).and of .,-x base

  Ace-Feder,)l Repottefs,  Inc.
              25  because I guess it was staff %,,,isOom 8 months ago this is exactl@-I





                                                                                                                           31





                           2                 DR.                 O.K.,  otlicr qvr,-@c,@ti-ons.

                           3

                                                                                      li@4,ve you got-  the hard
                           4                 That war,-,  %@'he eaE,,y     1) L% rt

                           5   part,  Har,old?
                           6                                                       ju,,-t rv@,n over two        or
                                              DR.  IIARGULIES:          Ie I,: y

                                                                                                                            rthc:c
                           7   other things                 qiiic','Ily because they niigh-'#-- take            somz   u
                           8   time.   we can come back to  i-lic,.ia becv,,Llse this  gets  to be quite

                           9   a long unifocal d.4.alogue.
                           10                 DR.  ILA.YER:   II--  are  listening.
                           11                 DR.  li@.R%I-IULIES:   The Cancer Center propose@l which was
                           12  reviewc-d by Cou@-ic.-'-.-,6  last til@@o                         for your
                           li  the  investrct-@.n-- bFsed       iip@n                            ct4oi-i of  $5 million
                           14  for a ca-sicer construction  cc,.nter in the I\Tortl,,cc@s-'c- par-,"  of the
                           15  United States.   That was  reviee@c-,d,  ai-iCt there h@,s bec:n  )avoralk,.Ip-,
                           16  action wi.th cert-"tiii recTu-46.y:,@ments  attached to it by  thc-,@ Co,17,iicil
                           17.1 for a  cancer co@nter in Seattle called the. Fred Ilutcl-iins:o.,,i
                           18, Cz,,ncer                 Cent--or.
                           19                 There were  sr.,-,-!cific rc--qui-rori,.cnts by  the Co@ancil  and
                           20  some  tlici@-- we  iin-l-)osc--d whi-cl-i h@,d to (lo with  such regulat4LOns
                           21  as  are  in     the logi@l&.ti.on-t  5,ii  F@t@l,tp-  regiilai:ion,  certSfilcate of
                           22  need and so on.   They  appear to bc- moving quite well  to

                           23  complete their requircm,@i-its.
                           241                 we  said that we woii)..d relcase  t-hc7-,                       oni-y
    Ace-Fedctal      Repoitr-,fs, Itic.
                           25  all of these requirement                          met.      So that the  award was  made,






                                                                                   32


                  I by           but              yLiLt,'-Ie P@.ward a
                  2 until al). of these                               Cou,,ici,l    ha%tc-t
                  3 an oppo,,-:Lunity to loo),: ;,t E?.CJEI:Lrl e,.t least in'Lomally to sce

                  4 if it -atie;fies
                  5           ProbEibly the key i.c;sue fo.. som,@ mf!icti@c@.cs of the
                  6 Council -v,,es the pl@:i-i to  pat4c,.iit beds in them researc-.h
                  7 center        iG co,,-ineckl--,--d w@i-tl-i Swodi.F@h by a ti@-,inr@l,
                  8 but which i-s not. a part of the building itsel.f.  And some
                  9 mairbers of the Cotircil fc,'@Ic \@c-,,,-y c;t)--oiigly tl,,Ett this
                  10 produce a good research onvivoxirpmit, )-)ui-- thEy x,:,orried abo,-i-@ thei,
                  11 adequacy Of rOgLIl@.r, arouiid.--'@te-clock irec3ical care in that

                  12 c'rcur,.standc,
                  13            DR.         It 3.s. go@-ng to be physi.oz,,Ily
                  14@ to Swedish, is that it?
                  15           DR. IIARGULIES:   Y@@s. And th.@y li,:%ve rec-p-ondcd r-how-'@nc-7
                    us ways in which they are go;-Ilg to give assurance of good
                  16
                    medical   care.  amid it is       to be iip to thci Council t(@ j ii (i
                  17
                    Iwhether that ass"::ance is adequate.
                  18,
                  1 9           DR.             Tlio@e, would be the only beds, I take

                    it.
                  20i
                               DR. I'IARGULIES:  For research purposes, yes.
                  21
                  22           1 donl@L.        kno-@%? how much to got into th3,.@, next
                  23 i.--sue bc-c use v,,e could spend a lot of time sl)c;-ci-ilatin,g oi-i -t.
                  24 I would be glad to speculate with you, and it is ,.n c-1cction
  Ace-Fedc(al Repoiteis, Inc. year, and that is the popular thing to do, but this has to do
                  25,







                 I with the        of tl-te          of the
                 2 authority and of the                        in 'ch,-- form of
                 3 two major forms of               You mc.,y reca.11   '%-,here was
                 4 new cancer authority pass-c-,,d to p@:odlL7,cc-, a special center for
                 5 cancer research c,,rid control. and tl@i@,re is a paral.lel bill for

                 6 managerient of heart disease.
                 7          This, of covr@,,e,       @e question              of
                 8 what relationship either of L-liese act"&vi4".i(-,s rciz.-4y have to the
                 9 Regional Medical- Programs Which are identified with the  same

                 10 diseases.
                 11-         It also raises the qtieL,-@ion 046 wliatlior there be
                 1 2  a           of       kii-,d -c-@f             F,,-,d

                 13' clirc,@-sci
                 14 neurological disea2es or     of tAic.,       I don't know

                 15 about that.
                 16          iTnat lias hap@-iic@d, howevc@-r, has b@-c-n a desire-,
                 171 in i--I-ie ce-.ncer bill to produce a    pzLthi,iav fro.-ii -'clie
                 181 cancer laboratory researc(i rirc-.zi to tli,@- doli@very of good care
                 191 tothe public wi--'L-h prevention, diagnosis, treatrcn4-,,

                 20 tion.
                 21          This (,-ould be    by              or
                 22 the control programs whiol'i iier(-- carried unCi-@,r ijic- Div,-.,;ion of
                 23 Chronic Diseases in the p@ist-@. It could be dor,@c@ I,,,y othcr
                 24iriechanisriis. It could be done by the National Coi-jr--er li,@Ftitutc-@

  Ace-Federal  Reporters,  Inc
                 25' managing the whole thing fr--jn the ro.,3cerch. end tL).tlie el@,live@r





                                                                                             3 4




                         I,. or j- could )D,@. Ctc,.ne
                     2 oLii, with prcgze,-m,,-    'tlie
                     3            Thc-.@3,,e has         z:, deci@ici-i. maO,,-- ai-. present z-boi-i-L"
                     4 what our actual i@!o-.),.ing r-elLt-;.on-ship wi.11 be ei@-ior witl-., tliL-.
                     5 National Cancdr                or t-.hc-, lqetiorial Iileart Brad Lung
                     6 Institute.  Toyaorrow I am to cio over aid t@ilk with a grovil@ of
                     71 people in the Natioiieti IL-art and Lung institu"&-,e about hea,u-t
                     8 and strol,,e activit-@"cs Bunch we rii.glit bc-. abl.e to cnrry ou-Ic in

                     9                   think the negotiations                   place
                     10 cr,,rrent'..y betv,@c@r-,n Offi(---o o--F the               and with
                     11 Bob I,,.;-irston ai-- Nlli to dec.-Ldc-@ how wo car.        this out.
                     12           I,.,rLat I hope for, i@-, a       of tile ,special caac@r
                   .13 intok@est@; @Tid special. heart vnd lung interests .,,-Ii-i.ch re-2,--ascnik-
                     14 1,@IIII's major interest and constituency wi.th tlioE;e in the Region,@-@-
                     151 Iip-dical            And i,7h @- i'@,T.,ny of us liop-a for would   if
                     16 the--e is a re-em,--rgcnc@. of the control p--rogrzm tIA,@t this be
                     17 desi-c@,.ned in such a Jay that it-, iicprov--s the de2.-Y.ve:L-y s,,,stcm
                     181 re-4zli-or then opc-irzti-ng in isole@ied seg,-cznts thereof.
                     19            But we. iq@.11 p@:o)@@-bl..y hav-c@ a clc-,,arc-r -@nsiqer to

                     20 that at some time in the future.
                     21            In the roc-.                          ci-ioucjh, jurt to
                     22 add to the- confusion of the picture, %,;lien @eiiatoL- Kennedy
                       exk@.ended our I.c-tgislzLtiorL, lie dl-ol?pcd the cateaoT--ical desi.gnat-Lo"
                     23
                     241 out c-ntS-rc--.Iy iiid Iiiit his total orf,,I@ha@,is on
  Ace--Fedecal  Repoitets,   Inc.
                     25 and.  the              of  delivery  of            ser%,,5.cEse So we  are






                                                                                                    35


                      1 in a cc;q.,itinuing period of time  of s4,-xugglc

                      2 issues -v,@l-iich, if you lead t@iought
                      3 events is not 1-2-Icc--ly  to o--cut in         i-ir-xt     yc-@irs.   I do not

                      4 know -v.-liat final arritngemc:,.@Tits will be car;:icd o-ot.
                      5              in the meantiri..a, it has caused us to look auai-n
                      6 more  sharply  at  hote  much   of   our   activities   are.   dealing   i-iith
                      7 heart disease, cancer,,                  c2@d )zid,.io@y           7@iid   they
                      81 still refrain a preponderant part of Regional Medical Progra4-ns.
                      9              I,?hat %..,e have clif'icult                             t."
                                                                     i,7:j-th, and it is dif; -c-,,E,!sing

                      10  that    dot is 'k-Ilie idea tliatyou cc.,n ).)y irr,,,LDrovi.rig -- we3.2.,
                      11    talked about it earlier -- total c.@@mc-,rgenc%r medical services

                                                                                                  a
                      12      a. coiitril.@ut-.@.C.,i to the control of hca)f,',,,             'Ph
                      13 never ci-i,.erges       the ],,.,-nd of               vre ptit torjc-)t--)-Ier.
                      14 If you are   tal3,,ing about a categorical disease activity in the
                      15 way most of the people                  at it  at  Viae  bu(lcjel--  end  like
                      16 to look at it, it has to be exc!uE;ively for a specific d4-sease
                      17 Within the:                  if not, they cz-,.nlt recognize it.
                      18 If  you  iir,.,orove  basic  priy@,iary  care  services  in   a   rural   area,
                      19 the assui-@iption is, I gubs!;, that so:,ielio-,q you do that alid
                      20 exclude heart disease, cancer, strol,.e, and Ici-dncy dic-c.---se z!rid
                      21 related diseases ijlicn in fact- -cha'l-- is w-i @,-bsiirdii-,y.
                      22             If you try to tote up what you ae doing in soii-- kind
                      23 of-  dollar: terfrs to impro%@c,                   of tl-l(;"-Ic di,,Car3cst it is
                      24 vory difficult to do.   Slid we are in that kind of a dialogue.                    i

  Ace-Fedetal Report(,,fs, Inc.
                      25 I have no ansiiers for you.





                                                                              36




                            D-fZ. IIAYER,.0
                                                               Harold?
                   2i       DI@. l,li2@IZGULII:Sl. orie @,nd     of these ol-hcrs

                   3
                   will come tip
                   4        W@,      issuc,,l the nc,-,.j )-,idnoy     very
                   5  and they are a'vailablc- to you.  7,,,ncl I think rather than cr o
                   6into de'--ail at the prosont timn, since we have been over quite
                   7abit of grou-rtO already t'AL4-s morx-iing, that @-,,e will bring up -LI-,--
                   8details of that at a point where you are actually  going  to
                   9deal with the subject. Or we can do it now  if  you  prefer,

                   10 Bill.  it i@s VP to you.
                   11        I have a more significant issue to deal with, tlioucjli,
                   12  'or the                    is tlia           of

                 .13 hl Ican do is zc@cd yo,,,, tl-i@.
                   14        %,,Ih@.t happened. i,@as th--@t- the central payroll converted
                   15 to a new system.  An old consultant timekeeper nu@ler was
                   16 used which resulted in ri@,ny consultant checl,,,s not I)cing
                   17, rcsc-,arch has been condnated to d,,),L,.bl.e cl-ic-ck on the consul@-&I'IW-----
                   18i no-c ppid and to clear up other-errors.  Hopafully, all work
                   19@ will be completed and c.1).c@cks wri'c-i.-,z-;n for: May 23, 1972, p@y

                   20, day.
                   21        In ot:l-ier wordc,, we opc,,ra.@L.e our pc@y systc--iii when we
                   22 change frbm an old system to a new system just as others do
                   23 ineffectively.  So that those who have not been paid have noL-
                   24 been paid beczit@se they 1-i@@.d wrong addresses, wro,-ig

  Ace-Fed(,tal   Rel,)ortets,    Inc.
                   2 5which the switcliover r@ianaaed to produce. And we will,  if





                                                                                                        37




                                                                                               lbo@y ge-s
                          1can gc@,L t@l@,          to           to        make          ove.)-@
                                            A

                          21 paid  lic,@ chou.I.d liavc--.
                          3            So.Te                               clear l@ac',: to 1F@ t

                          4octo)Der.
                          5            DR. SCIIERLXS:      It has been speculated that is a

                          6source of   fLiaid-'Lng for yoLi@.- eyp,--mdir,@g EMS
                          7                   I'GUI,IES:    2@o a ma-Ltc!L- of fac-,-,' i..7a lixilzc,,d it up
                                       DR.
                          8to                      in ano-i;lic@:c subrcci.ber syritem.       And if you
                          9don't get paid, you are go4lng to got a 10-year s%ibscrip@--ion to

                          10 the National Geo,@,ral;),I.ICI

                                       (Laught,.cr.)

                                       DR.             Ot.hnr

                          13           (lio response.)

                          14           Than)-. you very    r,,izch, Harold.
                          15           At the ri-zi'rz early 4-n the.., Yi,@cting of fixing dLzll-es,
                          16 I would lil,.e to tu%.-n to the calendars @-Thicli                          in
                          171 your no'L-,c-,,,books winder the fir@,;t tE@b @,7hi-ch is
                          18 "Calcnda"-" in air             i-o aet the limk @,7ith Cow-icil c@,, close,--
                          19 link to Cou.,icil a-L--        toy,@r-,orc-41!y   i:E not philosopli-'&call.y,
                          20 1 we ric,--d to   t@%lo dates o,-,t of the                   three

                          21 in the  sul@sequant yecir.
                          22           If you           pi-,t a c3.rcle around the Sept@Dcr 17-23
                          23@@ week,  a circle           t'ilo           15-19          and a
                                                                     -Y
                          241. around 'Cae I:,;-,y 1,6.-19 N-ic@ck,   we         to do is pic-@ir. AC..-o
   Ace-Federal   Reporters,    Inc.
                          251 days in that pe)-iod of tiiTa, each of those weeks, that you





                                                                                       3 8



                   1i,.,ould like to scheJule for
                                                                         -c, )?art of that

                   2going from four cycles to            cy@l@, y(-.,ar.
                   3             Preferenca is in Sr@,n'@-ey@r)or'?  l@lle arc-, noN@7 on a
                   4Thursday-Friday go.      Is that good, bz,,Ci,
                   5             Iiow about the 21st and 22nd of Sept-leral.)cr as

                   6possibilities?
                   7             Going once, tiqica,       right, cloiia.
                   8             In Januaryt is the 18-'L9 appropr3@<ite?
                   9             All ri-cht, other tirc,-3 durii-,g that
                   lo            DR. 7iNCRUI@4A: A-ny day emcc.@pt t).iit Fy@-id,,y. I 1-i avc;?

                   11 to be back in Seattle.

                   1 2
                   13            DR.           That -v;c.,illd  fin.,-,.
                   14            DR.          Fov@ is that, O.K.?
                   15            17-IOV, theiit of Jaiiii.-"L-y.
                   16            And in May 17-18 OL-' 14CY?
                   17                           The tl-Lilrd Frid@,,.y ir, out for me.
                   181           DR. IIAYER: Thcri        al@otit the 16-17?
                   19@           Dr,.. @,CPUM: Am 1 the only one tlat has this

                   20
                                 DR. I-L;N@YER: I don't hc-ar aryk,,ody i@ioining about 'L-hc-.
                   21
                   22 otl,.er cycle. Tiier is no i-aagli.c about Thu:-r--di,-y-r,.c-'@day.
                   23                   thcl'l the 16-17 of l@lay.
                                 O.K.p then        @qe liava said is 21-22 Scl)tcrrber,
                   24
  Ace-Fed(,ral [Reporters,  Inc. 17-18 January, and 1.6-17 i,lay, a,@ the nc-x-L- three gols.
                   25





                                                                                                                                 39


                             I                 I would              tO                  to            otlic@,):  additional

                                                                              i--y                              -c     -w
                             2                                                     per-L-irte,,xt  to tllc'-    L -Vic
                             3proccss  ii;sclf e-.s we  go th,,ovgli               the revile process  from

                             4p -dlj

                             5

                             6                 DR.  PAIIL:       Thai).It you,  Bill.
                             7                 First  of all#  I Donald                     to   Yr@-olii--ion   for    you    that
                             8   there  is  the d4.niier this  evening  at the  Flagship Restaur@Lrit

                             9   close by licrc-s  -r-O  i:lie
                             10                pnd,  Bob,  perhaps  you can give detail  z)rri-nc
                                                                                                                          ,eir,-nts

                             11 - ].,-it c@ r. Bvt this  is  soriteth4-rg thol.-              a):o    looking     foli@@P@rd     to
                             12                  do I,.&.va                 of-  tl,ic!              of         comi-.,iitteli,
                             13 laa.,v).ng.   Are@.                     -chp.-L  Llhc;,  o'L-.h,2i:c           of the.
                             14 1togelr-hc-r with staff would  I:).!,,e  to i-n,;et togc'L-Ihcr infori-arlly  did
                             15 ihave  an apportLiLnity to  socialize  and w-&rh  tho-le who are
                             16 departing well,  altho-,-,gh Ni-@ do ho.-c@- vl,e ha%,,e c),o-le  and

                             17                       t,,,3.th  c,-z-.ch  aiid every one.
                             18,@               I liavo  ju-st a                feet                               I
                             19 Marguli,es has                                                      th@it        have been
                             20 going  th@:cuah.   T%nd you                     ztg@tin ol,)vioi,@ly haje  a vr-,.-y  full
                             21 agenda o,'-' information  iteris  in Sep@l--cniber bec,--tuse  the program
                             22 does  con-cinue to  change.                Hoiiever,     L@y     remarks     are     much     roore

                             23 i-,ijndLrie  Ind  sp,@cific.
                             24                 Spec4-fically,  I -@;ould                    -@o  iiidica+----  t-licit the
    Ace-Fedefal  Repoitets,  liic. sta-f  anniversary review panel  is  continuing to  functi.o,.i Rely
                             25





                                                                                   0



                          d                   thc--,y
                     1  an
                     2          L,@ceu,,@e the appl.4lcat5.ons   cam3         th,@,m

                     31-iod lot 7--ccc-,ivc-.d
                     4Iv@o-S in this p:,-Ki.od along 41.11 of trick o@er @-jpc!cializo@d
                     5activities i--ho.' ne-ed to revi-e@,i in dertli pa:cticular
                     6programs and assign P-,-4-,orities.  These priorities are indicated
                     7to you in tlio             in the book*
                     8        Thcre are        few programs x4hi-ch are behind the
                     9  blue tab in the boo'.    you are not recTuired to take act@-on.,
                     10 Those           care 1.)aina b,-,oLiglit before this coy,-miit-Lcc,.
                     11  -for inl"orr-.,F@it-i-on pixrpot-!c,-s only.  The other applicctions for

                                      Cb
                                        ..Cr Cl@. rCqLI4  rtc
                                                        CC,  7ti@ll
                     12 or.@ rc on o                              i.ii3f7@ o'L ect4-on.

                     .13       T, o,, o r.
                                         I c3(.-) %-7@iit to               the.,
                     14 does have t@'@.c opportunity and p---i,vilege of rai.sii-ig a que-.@t-i.,-)n
                     15 abo,-, t- any pri,o@--ity @'i easily applicat4-on that the sl:(-Aff
                     161 rcv5.cw panel Assigned         of whether tl-iit
                     17 is bef-oxe you for action or fc)r iri@l-o-..-matioi-i oni.y.  A-.rd %@e
                                                                                  o..&. ngs
                     18, iii.11 be askii-ig you to fori@clly concur in -tho.,;c--
                     19 or to modify -L-.h--m as you fit.
                     20        Should you have              abou-t any
                     we v4,ill have the chief of the onerationLI b):,-Ancli
                     21
                     22 for that      propircd to present to you the basis on Bunch
                     23 those ratings -yie--ee csr,;-gno-d.  h,nc3 you sh"ld in this
                     24 connection that the ))i:@llicli  F-o-L- th;--'-- req5,.ori @..,as not a

  /,.ce -Federal Reporters, Inc
                     25 iT,,--mber of the voting team for -that application so that he





                                                                                       4  1




                                                         f y
                   1  %,7ould be. prcsc-iii--ing a sunrt          .11, of whztt.     F;tzifE
                   2  anniversary reviev7 panel. c,-onclti@ic;c3       to tl,.e

                   3  to reach tha,L, assigned pri.o-,;74-ty.
                   4            You will also note that  %,jc@  have  -IritroducLd  certain
                   5  ne,q for,-aa-s in the pc..pc-r worlz whi.c@i has  to you both a' the
                   6  tirt2 of sii:e visits and i,ii tr-@.-cTps of priiTL&ry aiid secondary
                   7  revieiv of the applications. Prid I bc-l-..L-v(,- you will see ve)--y
                   8  readily that the           of this hz,:.s b@lien to try to  tie  into
                   9  our analysis of the appl4-c@,ti-on in quc@s-t;ion the         criteria
                   1 0@,;)i.-Lch havc- been dr-,vc-3-opc,,d z,,.nd.        I.-cilig u,:-ed nol@-
                   11 'only by P,,,IPS, but ]:)y the RllPs themselves as thcy view the

                   12 progress of tll@-ir P2:ogr@,,is.
                   13'          There will be an opportunity provided '@-o this
                   14 corarLittee z).t the end of     rating tomo,--.-ow to cor@zc,-ci)t-' t@pr@n
                      and riiLYe cons@t-Iructive Su      -)s f o-zl- ro-odi f i  in th@,
                   15                            c-f q c@, c, t 3@. o i
                   16 new ],.inds of forms and so fo):@")i which we are  using.  we lici
                   17 that the info:-roatioi-i is being o).-gztiiize,,! rarliaps
                   181 for you, iparti.cul.arly for co.--apar,4.son purpoocE, bct@x,!e-aii Brad
                   19 ai-,iong p--ograms,since by haviii.g the i,toras
                   20 lines of the x:evicw criteria it is ).@iorc; possible now to re%ric@i
                   21 1One PrOgra:-a in corrpar.Lc-c)n -,(-,o z@-,iotl-icr a...Y-Lcl lo?-)!,@ at the similar
                   22 items of infox-matio.-i.
                   23            Intei-iial3,y, there certainly is not

                      I?--hat this 4-
                                    tie Ultimate      p
                                                   %,la, to prctr@c-tri-t
                   24                                 d,

   Ace-Fedetal F'cpotteis,  Inc.
                   25 fcel, however, that there i-s an  opportunity  J.-ic@re  to  im,@rove








                               2                                        it  i,,".)"d                    it  t@o  you  dc@           c   1.
                                                             ,,rative  arld rclorc,                                              the
                               3   perhaps  less  na"                                                   su',Ds@_@z:@@ncc  o,,.i
                               4   points  ii-i  qt,lc:@,-;tic)n.                              do  lool,'                d  to yol,.r
                               51  coinToent-@  z,,t  the  end  Of  the  r,,oeting  as  you have  had  an
                               6   opport;ui@i.ty  to  use  these  ne-vi  fol-nis.
                               7                    DR.  l,L7@Yr,).I,.     I  r,,-'gh
                                                                                                                                   each  of
                               8   you,  I  think,  at  your desk  h@..d  a  long  sheet  i-,,,Iiich  d,,i-as  here
                               9   the  May-Ju.,7ie  revic@q  cycl3o  szirj.?  recorfart,-.@iidatioii.,.@  oii  it N..,Iiich  you
                               10  n(--ed  to  liavc-  for  referral  as  @,ie  go  tl-irouch.
                                                    DR.  PAITL:    Pnd  it  is  the  fivo  applications  at  the

                               12    ))o@toi-a o-'   lcl-.,c                       a.-Le  h)@,4ricj
                               13                       pureness  only  once  arc  included                                     that
                               I A. tab  in  tbr--  bz@k  of your Y)oo)f-.,
                               15                    In  terms  of  the  NIS                                   in             a                I
                               16            'I@i,kci  to  a.E;k  11'r.                         to  pr-ia,@,,@nt  v@,,@-.,y  !)riefly  for
                               17  yoia ,.ihat  the  printouts  are  d,-sicl,,ned to  do.    And he has
                               18I dis-L-.ribi-itc2d                lEt):go-  binCc!@s  for you.
                               19                    Thcrc--  is  no  intent  to  havo@  yoa                   try  to  IoLi'i@  P@ t  o r
                               2 0 e-l@sorb  ojiy  su--'Ai                                       at the  table.                             those
                                                i.-lio liivc-.. br-,ei-i  as-cicfii,.Ci                   arid  sccox-.,dz@%-y
                               21  Of You
                               22  of  appliczitio,.Is                    alre@-&-v  rL-cei.ved  the  appropriate  P-"intout@,
                               23  packages.    And  this  merely  -.epre:,-ents  @i  co,;i.-tpi.).a-ci.on  fo-@-
                                                plication before  yoi.i  tod@ty  so  i-,l -,t  yoi-i i@dll                                  Fomc:
                               241 each  -t)?_

    Ace-Fedefal Repottefs,  Ir@.
                               25  1                        of  ho-vi the  II-.IS,  lqai-,iorixl









                                                                                          to your
                                                 zxnci       to
                                                                   @i,-%riso)cy Coilricil, ar,.d to be
                         2site visitors,

                                                                                       ti r
                                    offclc'-ivclv by 011):                 as @@ic-! 90  I oi-igh th
                         3used r@,ore
                         4 1revie@l process and analyL;'@"--9 Of 3:c2g4,Ons,   ool- to this co4-nnt4-t4--c-a
                         5             would indicate agaii-i that we 1
                                              ,Tjnittee site visitors for constructive
                         6and to our non-co
                         7suggestions as to live to being to you those ]@..-(,iids of
                                                                                           ed fashion
                         8inforirE;L'ion and present them to you i.n some
                         9that wi-11 be irore (-effective in accoiriplishing both site vi.sits
                                                                     f the regions' prog-a;i-!s.
                         10  and the anlaYSis and discussions 0
                         11          Now, with that slight introduction, -L wO',Il                     to

                                                 'to        P,
                         12                                                                  for     you
                         .13 riot                                                        bu-L-1 r h e  r
                         141 what the nature of the fc!rmet of ectch printout i-r, desigi-,.cd         to

                         151 do for you.
                         16@         And,, e,.g,-i,-n,  I                    as will, pirtict..3.la-.--ly
                         17 at the c,irl of tc:iio,--row's ir.-@e-cing oy., ciL- any      of co,.ir,.3e,
                         I e. tli@t yol-i so desire suggestions -as to how this             of
                         19i activity can be inp,.-oved to,serve your purpose-A bettor.

                         20           Frank.
                         21           MR.                   Thzuik   you,   Dr.    Pahl.
                         22           Vle put together     a  nuiTLber   of   p--intouts on e@..ch
                         23 region that  is  go4-llg  to  bc--  discu.-,@cd  lic@re  todrty and tomorrow.
                         And tl  ese  packages  were   p)-,eviously   r,,-rit   to   the   primary   and
                         24

   Ace-Fc@@eial    Reporter.@,    Inc
                         25' seconJary reviciiers for those regions that they had trader their.,








                                                                                        A,i

                   I responsibility.    So         t-l-ic,,y                        to you.
                   2            lie,      then, a,ll )-.', )cc.@(jioiis her-c! \,7ith the..
                   3 of the nc\.,r Oh,-,.o l@JIP. 1,Jo. hz@vo.          for eac,,h l@'t@P.
                   4 And if you Around be so kind i,4,; ju,-i- tc; tal;c@ your big bl@zick-
                   5 binder, maybe v;e could ri;n 'clirouch for a            or t@,7o the
                     kinds of thinc                           arhaps how you could us
                                    .,Ts @.7e have t-l-i(.!re -,,iid p,                  e
                   6

                   7 there in your deter,7t,.tiations.
                   8            First of all, they are- L@ll elpliabc'c-ic:,r@l, the P-@,IP,
                   9 startipg %,iith          ilicsouri, a,.id so forth,. Ile ha@v,e
                   10 redioc(2d t-lie p--4ntoUtS, as you known, f-rom tlio large siz@- \-@hicli
                   11   foL@nd            utiw;-eldy to this rceitic,-@d vey.-s3.on that you

                   12 s(-C- j.,-' 'rc-'@t o@' yo,,i.
                   131          if      could urz,,@ rc@r'@iaT
                   14 and run @irot).gh thk-- printout-,, in;.@.vbe that would be of
                   15           Thc-.- f5.rft          i-s c-t fu@rLdiritj history list @-@,hich
                   16 identifies for you ).or each R-','.LP all of tl-,,,, projects that
                   17 were ever supported by Rl,!.PS 'Lunds and then in each colur@,@.n by
                   18 year the r,.,toneys that we-e--e put into that activity.
                   19            For c->.ample, in the Kansas, you see there they have
                   20 it -i%.7ardod for fi-ve year,,,-. so the fi-vst five colul-pns are the     i
                   21 moneys that wej,,e a@-.,a-cded in cz,,.ch project and total at the botto-I
                   22 for each of those five years.
                                 To @ia right of the asterislz column are t-lio@,e
                   23
                     moneys th,@f- i:hc-y Zaire             at the-.::-, @iyre for sub!-.-,-CTIICrlt
                   24
  P,ce- Federal RLpottets, Inc. vc_lars, In the case of Kzinsas for years 06, 07, and 08. Ag@ii.n,
                   25i







                                                                                                45


                     I  at- tl-ie                                          requested.

                                                                                    C\;.ar
                     2             o.      r, o r    n c.,,  r  ri c. u  Y,:) LI 4 P

                     3      nuinbc@,r     ta@b.  The              OIL
                     4  for each       by typ,(,, of support being rcquestod, N.@hether it is
                     5  coi-itinL,,atiot.i N,7i.-Iiin ctr,,-,rov@d   of ,@upport, \@,,j'-iich i,,- the
                     6  firi:t coluir@n, continues beyond the appro%@ctd                of
                     7  wh-'-, cl-i is t-hc r,(.,cond     irtC4'   forch, tho,@,e- Yro,.-,c:ys tl-iat are
                     8  being requested for a particular year.                1
                     9              race page is a prog2:@-.rii period..  The fir.,;t page for
                     10 Yansas is their 06            of              The secoi-,,d pz@ge will I-,C, 074
                     1 1            At tl%c ric-fli-it  of th@, E@,,cfct,, yo,,i no-L orly have the
                     12         codes. b@c,.ing                         ti-,.c.;         a,-id -i--Io-t-l@.1

                     13 (Ioll',@ars.
                     14             Now,           the ntirt-.@)c;r /,. tab, i2,-ider Kansas, @.7e hav@,
                     15 ar,                    of       Rivi!13S ftii-i'ds tht@-t be-L-@ig

                     16 as a                of         sou@,-c(-;@, of
                     17             1,@Tcw, in tl),-@ -Arinal,,cial data rocord that@ the P@@


                           ,7.1
                     18 svbr its  to  -os oil  C-Etc,,L  prc)jc@ct,  tl-i@-,y  id@,rztify  i.'L  t--h,-DY C,@ 01-@ g
                     I 9to be getting    othc!,--          of SUPI?Ort for that activity,
                     20 And we hav,,@    sl--,Iayed th4 s in toriqs of                   in the   f i-st
                        coli,@i%.tn after the tit@.e tlic- IU@,iP-0 ftiiids    are, rc-,,quc-s-t(--d.
                     21
                        The secor-,d one is those fund,-- ';,-hat they have ind-',-cz@,ted %@2ill be
                     22
                                 4'roiit others                  the to%@,@tl thc-,,-i in the th,---cl
                     23
                     24  cr)],uivn.   A;-irl in -@ic E-ourth       is tli@-.t               of
  /kce-Fedei,il Rel)orters,  Inc. that RI,IPS iqould L)a coi-,.tribiitii@),g.
                     251
                        1








                                                                                                         A r%



                                                                                             they have
                                                       ol              zAs Y'O',' cr
                      2   ci t                                           supr-@c)xt for any of tl-,ci-.-

                      3
                      4               vie can go,     th--n, b@,l@.ind the             9  tz,,b  of   !Kansas,
                      5                                   that                 tire descriptor surpm@ir)-e.-i
                      6         had beon submitted to us by the R\IIIP.              We have this

                      7  b2:o):en do-.,.n in@@o three major groi).,-)angs.
                      8                @Phr-- firrt gro,,:tpinas are operational components.

                      9  in the case of Kv,-nasa, on the top left-hand co--ner, you cF-n
                      10  sea   that   they   a@-a   )7eqtie5ting   12   op@,r@@tional   coi-,nonents   v7hich
                          o                               each of the 12 raajor gro@ir.)ings of

                      12                                     have
                      13' for you that i,.u:ril) r of                 @li,,At          to  tliu,-@   spa("if4c
                      14              thc- dollars tha@t are                  and Leon the.
                      15  of Ic-hose dollars that that money identifies of the amount i;-hat

                      16  they are regi@,--sting.
                      17@              Thel--e are four pages for that                            p):intoi-it.
                      181 And then ri.gl4bt behind tlze litL-Ilr-@ yellow tab, we                  a SiT,114.:L--r
                      19  type of displ@ay for the pl.@,i-inii-ig                  tl t tlicy ha%,-e
                      20  iCcrlcified in t@lic@ir a-,pr@llicatibn @.;hich rLinE-,          se-ii,c pati-.c@rn,
                      21  the ntlp,.ber of programs that thcv are requesting axid @ie airotrt

                      221 of dollars.
                      23               And   the third batcl-i are the 1)@-oc.5rz,-Tri fE@aSi-bi.l.i-ty
                      24, stuo.-ics  and  cr-@ntral  services   again   in   a   siini).ar   i-.rrangorieiLt-s

   Ace-Federal      Ref)orters, Inc.
                      25  and array.





                                                                                                               4-. '7




                        I               The ne"t

                                                                                                        -,qu
                                                               -PI
                        2of thcir page 7 O'
                        3                oppo,-tLni@-.y d.,t -La thcy                          to i:,S.     Thf-,.co.
                        A.   are four mejo--                               beirg core stafc-,  again
                        5  broken doi,;n into                         technical and secre,:e@ri@il
                        6   and cler;-Calr  tile same                     fo@.- projc-@c-
                        7               The tl-iird Y,,,,ajol,-- col.u.,@L-i j.t,,j, i-,I-ie regional @@.dvi,.-oi-y

                          grou,p.
                        9               Anc3. -t--he          c ,-Lc-. othc-,,,x, coni,,,niti::c@,c@s.
                        10              The ro@,is,  I                 are self-explanatory.            The -cop
                        11      is total which are                        Then you have the
                        12                                      TI,@cii yc)ii have-, -L-lie broakdu%qn i,,,ndar
                        13                                                               I-.Iiat Fre
                        14 appropr4-ate to blacl,.s,  inaians,  Spanish,  oriental and
                           This i- a d-IL@cc-t--                f).-om         7 of their -zpplici@1--i-on.
                        15
                        1 6              The                     He          Provided for c-ac,,h @IP
                        17 behind T,-.b ie@ li@-s bcc.,TL               front the financial data
                           rc-or,is                h@v@-, id@-ri-Li.f4cd for t).icf7e. objcC,3 o' c@p@nditl2--
                           t"liat are on page 1G,                  4..n ezir-lil             th'--'-,   have   been
                        19

                           re,                                 -c@),
                        20    L)O::tc-cl to                          ir. i,, partic,ilc,-- co,-rp
                        21 first be3.ng     coca,, the r-:cc.@,Dlid oiic-t                       end           the
                           cor,.ir)o@'ien,L nui,:,bE:@.rs.  The, to-cal in c,,@,,,ch object of e)znenditure
                        22
                           for each T,,IP world be the                            riglit-heiid row of the
                        23
                           Izist page.      in Icl,,c czars-. of I-,aiisas, the last-- colui,,In oil pag,-@ 2.
                        24
   Ace-F(,-dei,il rzepoftcrs, Inc.       No%,i,  there is one oth(-@r set of printouts that                      have
                        251






                       I p)@- vd@,d N,.,hcli, is           for           of yo'@            t   to   do
                                                       'at-. the                                tl, e re  s
                       2 anc" "ly s i f3.   that i-E!                   )Da,ck of the bool@,
                       1
                       31 a tab that   ;-c identi:Cjc(l @,S                      )?I.7il@itout-,;, i f 1-7 cc-In
                       4 fli.p b,-@clc there i)-ndr-,r     14o. 10 toldr  the)-,c are foLr      d --L f f   t
                                          L.   @-t series    Pnd         these p!:jntouts ide-,ntif--
                       5 printouts in -'@hi                                                              .1
                       6 are those-,., RJ-.APf:, that Et-ro in this @.-c@-view cycle brok,,@-n down z,-ccDrO.-
                       7 ing to the ni:,,riibor of ycars that thcy are                             So you
                       8 can see that there ave four                 t,,hat ae-.,e in their first year
                       9 of operational, one in t'zlc-, sec,-;iid Hand so fo--U-i.
                       I 0                    can        thf,!                              is the sec@,-@qo-
                       11      from, the bottom             we hzAvo l@c,,c@n follo-,q4-ng              you
                       1 2c@.n sce                                            1 fc.,r five
                       13             Noii,                    a.@-         to              orl this
                         printout is a compc),r4-@--oi-L of tl-Le m(-,;-icys that t-hc-y a@re rLquesti.-i-,
                       14
                       15 in colu.Tin 3,  $1@.7 inillio,-x, @-ts a percentage of' thc.,.r ctirreiii--ly
                       16 bt).c7icjc-ted        in            2, $1.3 million.
                       17             In        tlli).-cl colui-iii requests is the percoi-it change f-c-
                       18 current.    You can scc they                            19.9 recent more
                         moneys in     total direc- cost than they are CUrrCn4l@, being
                       19

                         frknded for.
                       20
                       21              In the subsequent                  in t)-tat page-, we have alz;o
                         given you     a- ec),,c.@parison for you to see in terms of the history
                       22
                         of that W@P, tho pc,,rc,-,nta(je- clia-ii(,Yo 1-h@!.t occtirrci%.d i)-i  that
                       23
    0                  24           years I and 2 -- in this ca5e 177.7 percent.   Rnd their
   Ace-Fedf,@ial Repoftf-rs,  Iiic'I@.c -,c-cor).d column would hc,      yca;.E; 2 --u-id 3, a I:)ll@ 27
                       251






                                                                                                                                                   4 9



                                  percent  and  so  f or--th  doi,;n  -che
                                 2                             there  are  four                                 to  this  sc@ries.
                                 3first  page  that  we  have  gart@-                                is  to,@.z:l  diy,cct  cost.                The
                                 4second  page  has  to  do  for  corn  comi:>oxic-,,n-i;s,  thc-v  third  one  for
                                 5pro4act  and  the  foi-irl@h  for  -I--'Iiosci  th,-tt.                               develol?ivent@il

                                 6 CoTaDonentS,,

                                 7                    Yost Siste):.
                                 8                    SISTER AlqN  TOSEPlill@]-@                   I  am  interested  in  this  five

                                 9    Y(--ars.
                                 10                           1.1,A.YER.-     Sir@ter, could you title the rtil@.crophoric-?
                                 11                    SISTER PNN  UTOSEPHII,@:                    in  this  five-year  ope---@it.t.ona
                                 12 a.,@ you loo't, at                                                   and yct,. lool@. F,,@t tl-",-c
                                 .13 bucg@t and zcquested, immediately the qii.,-@s-L-ion cr-@,,c@s up
                                 14 is changing there? Becatiz!,c it is changing very rapidly.
                                 15                    IIR. ICHINOT;-7SKI:              In the case of Kansas, they arc
                                 16 requesting $1.7 million. Nnd they are currently being suiDpo2-'k-el@

                                 17 at the $1.3 million ic-vol.
                                 18                    SISTER PI,7,N  JOSEI-,HlriF,;.               I am tal1r.ing aboat Missouri.
                                 19       I look             tl-iose ti-.,o,- they z-,ro I.,ei.ng J'ui-).ded                        $1.9, and
                                 20 til-ay are rclquesting $4.4. There are some signiL'i-c@-nt ch@-,ge@s

                                 21 tal-,ing place here.
                                 22                     14R. ICHIII@OWSKI:               In 1,@issouri? I believe yoLi                             I 1
                                 23  discuss that at the time thc4                                                                          to IDa

                                 24  p e@gented.

     Ace-Fedeial F@cpotters,  Inc.
                                 25                     SISTER ANN JOSEPIIINE:                       This could highlight -L-hefe







                    1of           sur23?,@se oii(-,, -v.7ou.I.d 1C)r,)" Z',t.
                    2            MR.                That is tile j.yltert of Fly covr-@ri.-.,Lg

                    3this.
                    4            SISTER AIRI JOSEPli!N'E:  I kc-op liolnirLg we     the rigl-it
                    5questions   because if  -v@ don't,     work on the x@irorct answe-s.
                    6            MR. ICIIINOI-ZSKI:  Are tllcrc-, -my otller qucstio-,is?

                    7            MR. HILTON:  Yes"

                    8            DR. MAYER:  Yost Mr.         on.
                    9            MR. HILTON:  Is the current plan to have those
                    10 p"intoul;s replace rau--h of the reacli@ng           v;c h@ive in the
                    11 'ot)-ter book?  Is thi-s the -;.dca,?

                    12.                              Ye@.
                                                If,-  there-,         to       -'L"hi.s p):i, i-  'L.
                    13

                    14  clearer? Somo of @ic@c-e           z,.re
                    15                               vc-r,. lie hav,-- juct in -'--his
                    16  -Iiade the doci.sioli to go f@.-om  large printout to the rccl-
                                                                                             d

                    17  printout. It is nn internal problem with tile use of a x@-ron
                    18. 7000         in tlic- building hore.  And if        c,-@n g,-t to use

                    19
                      the Bruning or one of tire other                           are
                      for ri-ght now and get it                  tcd i:athc,,.r tl)an @ero-c-d,,
                    20                                                         1.
                    21 wr-- can        the  quality         f caiitly.  And I belic,,re by
                    22 the nex-L  urge these printouts    are presented to you, you
                    23 note the difference in I-.hc,, quc,,.Ii-ty.
                    24            DR. I.IAYErl,: T;.-iat i!; extrc-,@i,cly    dzi-il-a. I,.71i c@ n  I

   Ace-Fcderat  Reportefs,  Inc.
                    25   f-cd to d4-@raecIL- out that-, "noi-i" Ohio prog--z-,-m, I i@ioul(I hav<,,






                                                                                             51


                      my eye teet-.h f Or thi,@c4 d@.ta. 7,,,r@d 1     ju,@t ci.Lkc.,d to t,,--y to
                    2 gc-,t sorie                        thz.,,t
                    3 yo way you CZ-,n vie,,,; tile tj-.-@lig 3.n z,,   P4-c@tr,.,:o over
                    4 without so,-te fc(@,ling of this I-,i-nd oe data dj,_,,I@layc-d.  rehc--re is
                    5 just no w@,-@,y if yo-ti hovr--i-ilt begin involved,   :Le !:-t tlir-,t I ccin
                    6 capture, viithout this kir.,d of in:Eol-raotion.      it is absolutely

                    7 esse,-iti-al.
                    8             MR. IIILTON.    Pc@,rliaps this is a question for Dr. Pahl.
                    9 1 notice c-:o:,ic-'nei-@ colors in tire forra.  Ir, there a color cc,,,-qil-lg
                    10                        Do--s it mcan                 O--     we jus:t

                    11                     surplus Pape-"?
                    12            DR.          fall; to                          Lin,   I
                    13 to ejo throigh it wi-tl-t                     hr@:c@-.I      sure @--he

                    14 v-iiJ.1 checl: r,,iy accurz?.cy,
                    15            The Sta@--'f 7,,.iniversary Re\@iew, Panel acts on oi,.Iy
                    16 certain tvpas of                     you wi.11 re-call.    7And N..7@ien tlicl,
                    17 dot the repo&-t of'- that panel    is givei-i c)n -,ort of this p4.nk

                    18 sheet.
                    19            DR.                 It @.s good you askE,,cl him.     I art

                    20 color blind.
                    21            DR. PAliL:    P. yalloii sheet ind4-catec, tl-ia-t       is a
                    22 -L--aff docuiT,.ent for use by the- ccycirLi-ttoe @,,nd th(-- S@'L-,Pff
                    23 Anniversa,,--,v lzcview Panel has not acted.      Thcrc@for(--, this ).@ii-id
                    24 of staff sr,,-,saary is corai,ng to yrju as @,.n

  Ac,e-Feder,il ficporteis,  Inc.
                      without pxior review by ai,. internal staff panel.
                    25i





                                                                                                                             52




                                                                                                                               i o n
                                                                                             tli,e back-up info


                                                                    c3.c)     have
                           2                                                                ther color.-?
                           3                                        No,            only o@lic little-,  -f-@hing tl-,z-t
                           4 jarred us-,             th,@it is  thct-.            p-rilltdi.- coritrz,,c-tc@d out@- ar@d,
                           5 tl-iorefo)-@c,  we hu,@e Several  shaci-es of the  sarc,3  color.                         A p4-nk
                           6 is  a pink,  no iTiatter N..lhak-.  4-ts  shade is.                 It dep--nds on what

                           7 contrz;ctor
                           8                          IIILTC),N-.  I-,'hat is  a salinon',>
                           9                  MRS.  KYTTLr@-.               Hiltcn,  the  salrion indicates
                           I 0                                                        review of tl,.-c  Staff 7-u-in4Ver-
                             generated        by        f  f   or the

                           11   -Cary


                           12
                           131                                             ar(-! z@1-1
                           14                 DR.  1,1@'iYEP@:
                           15                  DR.               I do hzw,-- oii,@' or tx,7o points  of
                           16                  7uicl   Ichcn    I
                               for      you                                               to st te  about
                                          3-s.      o I c-, t r O.                                 ,,o points  rolativt',%
                           1 7 PrOPOsa                          o  tal-o up the  first ti

                           18  to
                                               Thc-,rc-. lio-.s bEa,-i ove.,.,           rLlo.,ntlis
                           19@
                               need by P-TI-T-s' fo-@ a cl-c@a).-                        fr-o,,,a         rel.ativl- to
                           20
                               responsibilities  Lnd                                     of -the. grantee, the rkAG and
                           21
                               the  coordi.ni:@IL-.or.        llxd                       of s,L-,aff Niorl,. have no,@%7 gone.          i
                           22  into a statement            -Yihich h,@s     bc!,2n Ic-,@31,-,cd E-,t by the. steering
                           23


                                          _eC_
                                             , of A- IC.
                           24  c 0 c@rq                    coordinators i@iid           has.                  the @-pprovai

   Ace-Fedeial Repotters,  liic.
                               of the      HSI,!IRLA grants policy office.                 And @,ie will be getting               out
                           25@








                       ho      Ily      1-i -,n th-               t-,,;o       c-t  St

                     2                       and                    of  l@,7NG,  g

                     3

                     4              rioe;, i.,,e are       that I)y m@,lzi,,Ig this
                     5 and it -will be policy, thcr-c., i@ii!J. have to                nic)dificzi---'Lons

                     I
                     0 in some of the ri,'iP regions' by-1c,,,.i,7s @..nd                     F,-Ut in
                     7 general this is x.,,,hat the dixectoi@- zmcl I-IS.@Hl@ @nd the steciing
                     8                  tl).e. coordinator believe  is apnror.)riate.        Ar, d

                     9 since it is             )-P-ng-thy, I               it into -'Che rc.@c-n@.,d.
                     10@            We do not ha%re it for you today.   We have bce.vi
                     11                          to m@@@o suc.',i a dc;@cllinr@, bu-L- h@.ve, bc.;t-,.n

                     12 unabl@e tc) galt-I the hSi-@14il@P.           o,.- @r to do so.
                     13'            Th-e %ta-lue  of        I           v@,ill b-c.     for olica

                                                       4ty
                     14-                              n     f r both -he rc,@4ori.-s c@nd
                       there N,7@-'Ll be air opport-Li
                     15  orgznizL,'L-.j.onal groups and cars to have a ccr,,-,non docun-..@tnt to
                     16 look al@- z,,@ v,@         pro!-)Icru @,7hi.ch do &Lric-@e in the

                     17
                     181            In             the key statc-.rc,.,@nt i@,Thich ha@s bec@-ii i t,-: c-,. 1 f
                     19 so   easy   to read and has t@,)@:cn so long to get clca--anca       on, 1
                     20       lilrr-- to      into the 2.-c-cord bctcatise I think the      @est o@L

                     21 it airiplif;-es this
                     22             The            organization @,h@ill mari;-,.gc.,,. the gr@,i-it of

                     23
                       the Regi.onal              Prog.-z@i,,i in a inanner i,.lhich N@7ill
    0
                     24 the p%-ogran estcbl-@sl-icd by the,               Adv-'@:7,o-@-y GrouT-@ in

   Ace-Fedetal Repotters,  lfic.
                     2511 accordance witli Federal regulations and        policies.










                                                                       c-                     Cj I rI
                                   A,, 1. d              C' a I'l I:,ffDf i t -

                     2 O@c-,tail i;hc ro),c, slid                    Of the,
                     3 Regio.,-ial Advisoy.,,y G,-oL@p Ilcl                   %Iho in this docL@,--Cn@
                     4 is also idei-itified vs k--hc- chief                 Of'Licer.    And i C'.
                     5 represents, I thi.nk, a major step fori-7ard.  And there will be
                     6 @rome specific, isolated                   but, roost of the proL-lems
                     7 which have arisen iy.-e               of                         and

                     8 of agreement as to a common theme.
                     9            S o vie do hore that this                in better understai-idi-n-";@
                     I 0i-nd rela4k-,ionshil)s.  And o,.,c-r the couy-,se of the year, I a-m, sure,
                            few rj-?-acific py.@oblc-.,ms wi.11 bo al)le to b-S          out. Oil a

                     12           e 'b a, r,
                                   14ISS @l,!D' ""SON:       you going to               the      e - u p
                     14 of the R,:r@G end definitions of -Y.,hat co,@-as-i@mor is?
                     15             DR. PPHL:  Not in this docu-T,.!@i-it.  As vie 1-iave broti.-ht
                     16 before you at earli.e2:             the;:e is ci                 by    the
                     17 D@partment tha7.t mo@.-e            of z,.ll I-IT@;q          be put- -@n-co
                     18 )-,c-,,gulat-4.cns.  This is a          by tl,.,-- Secret@,nl,ls  office!,
                     19 and we ar,e p.-,.-oceedi.ng as we d,-@velop                       to ti-ic@ri
                     20 couch there in broader, more       gc-,iieral language in terms of
                       regulations.   We z@re trying       to   keep   the   formal   regulat4-ons
                     21
                     22 as broad as possibt.c! to prov.;.eic                              @Lo botj.,l the
                     23 regions and oursel.vc--f--. Fnd to use these statem(?nt:z to TnE@l!.-e.
                           licit what ic@.. ui-iCcrstoo6 Fi-Ld i.i-itai-idecl and
                     241 CxP
   Ace-Fedetil  f@eportefs,  Inc.  i
                     25             But the points yoii mentioned are no-fk-- in. this










                          I   doctL,,@cr@t &.rid
                                                                                              c@C-t of  f -Lirthc;,r

                          2   Thec@e                      e, @,,'hil,(@  t-0  g@-t  c-,VC"---:-Y).)Ody  to C07,-,e3  to


                          3    agreement on.

                          4                    DR.  1-11,:,YER-.   When                      be    released,  H(z-,rb?

                          5
                                               DR. 'PZ@,!iL:     It has bcc-n  clc,.a,-c-.d        by HSi.,iiF@.     I   @,,You.Id

                          0   expect in the ne,-.L-  Lwo wc--c-ks wc-, would be                    i).ble  to begin

                          7   ir@echanic@lly getting thom px@inted  and ol:4t.

                          8                    The second point  I %,-!ould mD7.-t,'cion  is  th@,t                           ii,-is

                          9   now established a policy effective                                   11  --  and thi,.@  i-s onl%@,

                        10    fo4- you-@ inforrRatici.-I -- which now makes it a require.T@ant,
                        11    places i-t as a                                or,. all              programs   to   info-M

                                           operate                                 diroct--r@:@: of a-n5r
                        12   tllc@           ..             I                                                                   .1@ -   I

                        .13   o@.- con,-ract to bc-                                in that@ 11-@'W
                        14    to  that  regional  health  director  the   opportunity   to   coTrcsnt

                        15    upon prior to the final decio4-ori eith,--).@:                               or contra(@li--.
                        16    H@ is             required to subriit                            but he              be provided

                        17@   i-12-0 OPI?Or-t.Lin-@i-.y  i;o
                        181                    It also is a                             that onQo  the  d4.spositi-oi-I
                        19    has been r,-tade, c-il-h,@,r approvlo.:L or                                         a@;7ard
                        20            info,@i-,iat--',.on mu@-t be giv ).-L bacl@ t-.o tl)e region@l health

                              director. obviously, tli4-s is -n tho iTitL-re@;t o@' lr,.-epiriq  Iiiri
                        21

                              better info,--i-,,ad about all acti%pities, N@liL-thc-,,r they ctre
                        22  1
                        23  1 in his office or not, but \,.,h4lcli coi-.ic from IJ.Sl,!A'IA.  7ind %,.,e
                        24    already                          this                    to our grc,,iit z),c-rivii;y iii

   ,ce-Federal f?er)orters, Inc,
                              i,ic are  soliciting  for  c@arrent  applications  to  go  to  the  June
                        25






                                                                                      ii G




                     Icouiici@l.,
                     2applications, and also 'the oiLcs L@cfo.-L.      If thL-.re
                     3not bcen                    -,o            the rcg.-,.onal health

                     4director i.z-i I)roviC,.ing hira th@@l- oln
                              I                      ,-   I@o):tutii--y to       them

                     5prior to this Jrne Cotzic-;@.l.
                     6          And then     viill be-                     in an
                     7way for the c@,i-IL-ract           wl-iich the. Ofx@ic.-('- of f@-ha
                     8Director of PAIRS dc,cs engage in.
                     9          I".OV, I woizld like to turn to the last iLein.  Arid
                     I 01 am sor.-y there e@rc@ so ni ny IL-hi-i,.gs- this i@; relativ,@lar
                     11 ir,.portant.  And with your poryciissioii, I would     to retd to
                     1 2yoll the                                          b@--.,@ii    to
               .13  YOu-   @lid 4--'c i@, di-)'f,.-.,ul-t fo-,,' you.. Lo s-,)-c-ct out -ch-rse
                     14 iml?--r-tant Paracrrzir)h@-.
                     151        As Dr. 1,4iirgulies iyie@---catcd, %@l,c! have        tl,.e
                     16 revised           and loc-@,l
                     for the ),.j.dncy                     of MTS.     Dr. I-linirian
                     17
                     181 pick up %@@he.-e I   o,"f.' @,ncl   th-,,;ii ).c--,--,.d ii-ii--o i
                     19@ discussio,,i of t@ic,-e          Bli'L.II i,.,ould   to go ovor
                     20 the revie,,i proce5s ;.,ith you @,nd as a rviz-4.ttor of
                     21 YO" slid aico as PFrt of 01-ir ;-,(-Ico,.-d rc,@@t(I to yoi:. those
                     22 i@7hich a-rc--; per-('--inent to th.c- revi.ei4 r)roccss and Ic-@,ive to D,.--.
                     Iliriman to then d4@sciiss the more general state-,iieiit about the
                     23
                     24 Icidney p--:-og.-am objec@@ives and sp,--,cifics     to tlii,.s
   Ace-Fedeta@   f@c-poitcis,    Inc. meeting and kidney applications.
                     25






                                                                                                                              57


                            I                 Th(--)-e                                            ur    c> f     fort in
                                                                                                    it
                            2  trying                                              e4nd                          -.',.ilto
                            3  lot m-o  re.@-cl to you,                          the-,               of  -L-he  review-.,
                            4  process  at the  local  Laid tl-i-a ii@tio-,ial                         is  @,,.h..ch  is
                               Effective n@,7 and,                                             to Lhe  -zctivities  of
                            5

                            6  the )Teeting of this
                            7                                               the  -It-lechiiic,@-.1              process  @,t
                            8  tbe  local  lcvcl  and                            z44bout in-.-.tial discussions %,7hicl-i
                            9  may occur botA,@,@c-n the  reg4-on and P-7@IPS  st@ff  as  a  co,,,-icop-t  for
                            10 a ki.dney                                    bu',--  Starting with  @.e  technical
                            11 review process  at the  local                            thc-,  i,@,sucxice
                            12                           to                                         -'o2:  a
                            13                            thc-          is  c,,-"nact:cd tc)  ol)tcxin  a tec,i-iiiical
                            14 review of th,,@ proposal by a group N,.Fhich has not
                            15 the                                           TI@e.  i-c                         g@--oup r@,ust

                            16 be
                                                                      c!cl by  'chc-  region,         Pa-Nrivstit- of           ca '@@S
                            17 tllc  ga0graDII-c
                            181, of  such                                            be rtaC,.,P. by the  Y--Cqu(@c@tiiig I'@,:P.

                                               T
                            19 1                 hc,, :(-cgioa i-@y Obtain  the                      of co,.i,-@ult.4ng

                                                        4 ri
                                                                            op        t-@
                               c>@Loct)--ts  by                                                                         f oLr
                            20
                            21 a.-                  The                   of                         E,.i-,d Tc@C.',inical
                               IDe\Felopm--nt raniiitai,n,-,@  z,.  IiEt       of  roxial  consultc,,nt,-@,  and is
                            22
                            23 rc-@;PO!Isibl,c  -J'-or                                   assicjr@,-.@cnt.      .131ioul-d -L-lic.
                            24 dc,@s-ire to  chooe;c  its ci,.,ri  review                              i-iarv,.es  aid
    Ace-Fedefat Repoftefs,  Inc. Nri@.tiQ  of prospective  (--oNisultant.,@  riurt bc-  cleire(:i with the
                            25






                                                                                                           5 el



                                 ci @-L C)                                              )Pl c n*-

                                                               of   ren                  'IC-'C.'d )"Ot

                                      ready by                                           mav be
                         by iaail @,,,Iic,@n                  The    R14P       nego'c"ate &.ny
                     51  needz-,d -@@,o-old conflicting I-echnical advice be gi%ren,bv                  a
                                                                                                        ,h



                     6
                     7                Forwc-)@.'.-@i i-r@g              onl.y those proposals x-:hi,ch cited
                     8!                  favo,--c-bly by         local   tachn-&cal    revic-ii    g2:012P
                     9   sh@-11 br-- c,@l-Agi-ble @o--                     by r@TIPS.    In addilcioi-1,
                     10  an oppor-c-uni;-_y         b-@ pro,,rici@2d py.-io2: to                     of -IL-he
                                                T@G for rcvi.c@@,i a,l               bN@       appr-c.-,pri.E,,te
                     11  prono a-I bv the P                             d
                                                                         by F>,@r;ti     9.04 (@b)
                     12  CI'P           0

                     13  A c
                     14                The RAk"3 sliall con.,@,3.,eor any CIILI@               and

                     15  on the        1. - ty oF the IL!,ill to rLiai@ c,. (7 @'i
                                                                           t' a, kid:-icy I?-o-'oci-    1-hout

                         hind--ririq the d,@-,Fc--Iopraent  of  the  ovciy-,v@ll  r@l'.P  p,,:og
                     16                                                                                    tlic-
                         reasonableness    and    adeqlie-cy    of    the                    propo,.-,ed.
                     17
                         The RAG is respo.-.s4.blc@ a!E;o @@o.- ii),d,.ca@-i-ng           ira@or ;-Ssue,-l
                     181
                     19  raiscd by the locz@.1 to--!'Inical                  ql@-oup Still  I-,e
                     20                Since kidney p-opo-lals arc revie@qed separately at tllel
                         nation,-A3. I.eNiel,  the- RhG iic,,,--d not give(!               ranl,.ing   to
                     21
                     22  )-idney p-"oposals in relation to other non-kj,.C-iiey RIIP o_                     @on@.-@,,
                     23  activities.   Kidney proposals.                   be consido@.-o-(-l by  r@i@lP@ i n
                     24  relation to national priorities.

   Ace-Fedetat Repoitcis, Inc.
                     25                The col-,iplc@tc- constants of the       me@ers of the technic,-.i
                                                                                                                .i









                                           c--r. d  a n y1 .1 P
                                                                         i- i t r@ r@i ubc i,-i c:;


                     2 ii-i thef      d,,:,(,-;
                     3              ILIVIPS                the.                              sh@,ill

                     4 include:
                     5              a.  The co;.-itribution of -t.-he project

                     6 program 0))j,-;.clcivest
                     7              b.  The                  end i,,.@ttire of tl-ie          of

                     8 the RAG.

                     9              c.  Coir,,Tants of CliP agencies.
                     10             d,. The preferi-cd            of fu,,idi.iig.
                     11             lu,,PS Review Cont:ni-@",tce - PL@IPS E,@taff- w,..Il

                     12 t-h@-

                                          pl-,op oses to suppoz.-t@
                     14 objectives, F@id --ho substantive points,                   thro,,Ic,,h 10CE"l
                     15 review procesEes by the Tc@ch-n@'.,cal                              l@1-7@G,
                     16 thc- CIIP Lgen@y,   For                                      the @,.G-,
                     17 CHP   @,gency;                   or.                            has
                     18iii(f,.ic    a concr--rr, @tpE@):. oiii thc- technical Yr-o--i-ts of @@h,--
                     19 project, the R.',!PS Pc@vic-@y.,          w.-!.l'L be       to        Fa
                     20 recoy,-,nL2nd&,tio,- to the lle.11--ioiial       CoL@.,icil.
                     21             The 111,1@PS                    sy@,ici--Fically v7ill not
                     22 rc@vicvl    on a t(--cAllnical basis thc@ r@,,--rit of I:Iie pro-,oosal, or
                     23 c s t -@ 1 is li formal. nu,,i;arical Yati.ngs for individi:,.al
                     24             rind., finall,y, secti.oi-L 6, Cotincil

   Ace-Fedctal Repotteis,  Inc.
                       pronosals    shall be siab:Tti-t-'I--ed to the ilatior!,vl Acl\,,iso@y Cc)u--,Icil
                     25






                                                                                                               6  0



                                                                                  \.jit-,-h tli,-@ c to .,c@@l
                        1  for fin,)-l              I C4,., tj                                          r4
                        2  ii;it,-,re of the ]@icbi@!y disease,,                 @@;,.'LLhin        the   Cok.-a@.cil

                        3  will reviev7 z).nd. reco,,,@iRieiid furidix).g Ic-v(,-@l,@, @o;c kid:-i-o-y  prcip,-)sEils
                        4  Separately from tha   funding le%rel of the                               R.%-IP.   I'@idricy
                        5  program fvliding will be in addition to other Rl,!P program fu,-,,idi-n@.,
                        6                 Noei,   those   are   pages   3   and   4   of   this    4@ssuance.    Zind
                        7  1 would like before i@.-a entert@i.4.n dic@cu..@-.rion,
                           this is not i-n the co,,r@iDlete                         to havr--@ Dr.  Hinmc,,@n
                        8
                        9  have distributed to you                    which            'ust &f;-Nsued and
                        10 corxcent on so2ne o'A-           othe2: features of         this       i-lamely,    the
                        11 'frar,,awork of kidney program, ob@E@c-k-.ives,

                        12                DR.


                        141               DT.I. PPXL:   Of coursc-.,,.
                        15                DR. I.IAYER:     -- to           @ure  v,,e.  have  got  that  iLid@-r-

                        16 Eitood?
                        17                DP,. PAI T f.. Of  courrc-,,  J3i.11.
                        181                          i,,Iiat- I          do  -is  indicates, to I,,ou            the
                                                    roLponsibilii--4-Es        are o,.i p--ge 4, iteni 5,  a,,@,d
                        19
                                                  r.                    up perhaps the two of us
                        20 if we can I-Lave D
                           can try to rcspond tc@c@-c-!I--her              Dr.                  to 'the
                        21
                           questions that may be raised@
                        22
                        23                DR.    @IAYEI@:    I guess my problem relates to how u,3
                        24 dL-al with     this., We are not dcaling wit             1--i the technical asr"@cts
   @4Lce-Fedetil l@epottefs,  Inc' of   it.   We   are   dealing   with   its   presumed   relatio:islxip   to   the
                        251






                                                                                                                   6 1



                           re,,,t of the                                     Is thz@.t cor),c@ct?
                        2                 I air,           to         a fc;c,;l for,          is        @,-ole

                        3                 the )z@.d.-ic;,y pro-;cc'c-.-s.
                        I                 DR.  P'illL:   iic-1.1,  this  issuance cE.-,Y@,e about as a result
                        5  of the extended discussic@n at the I.;ist corr;,,r@ittee nic:;c@,tiiicj r@d
                        6  at the Cov,,ncil                      to that rctocting.         2'@nd             in
                        7  ordc-,-- to                  it,  Di:.                  cc-u-i reiterate,  I tI.14-1-11c,
                        8  @-?hat        et               to the cor,,L?.iiiL@tee that afternoon of the
                        9  second day and which has been                             ii-t tlio principles

                                C 4
                        10 enun Latcd hero.

                        11                So 1.@et      ask Harold

                        12                                 I ncoi3. to            F'.

                                                           of                          frc,-Y!i t.@-!C-@h;-iical    s
                        13            @.,,41;h  c.@z?ivLy:?                   I                                   ,t

                                                       fincs z,.F, this           what k@,ncl of               4s th"-
                        14 i.@Iiicli is -v.@hal-- it d,,-
                                          DR.  l,il@RCLJYIES      I thin',,- the most                              h2r@,
                        15
                        16 is tli-@. one tlia-t                     will-,. over quite zi pt--ri.od cf
                        17 Artd that is the                           bet@..een a propo2;ed kidney

                                                      -'tccil.'Iy
                        18 iiliich may b   teel-,r,                    7factory ard a Pc;cjional l@.@-dical

                                                                     pi.obl-r,.-i-c. with it..
                        19 ProgrE,@.r@i @,,,Iiich i,,,,Liy hove bcji
                        20                                                     operating worth,  at 1-oz,.st,
                        21 the i7nplic4l.t                                       wl-iic-l-l i-7as in real t,-ou';])l-@
                                     bably    not a very good site for the cstz,@lishiTtE,,rit of all
                        22 was Pro
                        23 effective                        kiid,-, y prc)@,@.r m.   Th;jt @1.)pca:ccd @i-L M@ai-iy

                        24 wayF, to be z,.s a. (,lejif@)Tal

   Ace-Fe(ler,,il Repoitefs,  Inc.
                        25 coo wh---,-L- @@e would isk the review coraiittoo to do with tl-iL@t kirid





                                                                                                   62


                             q" u":3 'c,oL  j@,r;        y  t         -,;,2 0 ri r 0C! %4 0 f Ii
                                                                                             d

                     2                                   I)Y              mc-z@iiing when vou see
                                      y
                     3 a  k",-Cney                   lias gorc-, @.-t.-oi:;gh technical rc-vic-,.w and
                     4 is                 bu-i-- it is in a r, g4lo,-ial l@ic.-dicEil Prog:can,, L,,!>Olzt
                     5        You         som-@,                                 should     O,,-,      that
                     6 Occas'On  raise  those  doubts  and 7,.alce  some  kind of  decision
                     7 abou-L. @.7liether  i-L.  is             for  that  @RYIP  and not       itsel@4--
                     8 to  carry  out  a  technical.  rev4"cw,  to  --,-2cond  tl-.e  tocl-iiiical  rc!v,ic-,-e,,
                     9 @.;hich  1-ias  E,,Irc@.dy b,'en             So  it  really is  actioi@,. by

                     10 excep-c.-i-on  i.ii  i-ho-Ic
                                    DR.  1,1,1@YER:I         my  p2.-cbl,cm  is  I  cci!i          of

                                             CEr, LiFc@t                      a
                     12                                                                    r.,Ct C.-Illy
                     13 tc-chn       b,@t-                    -c-d.  3                  .9.,)  1  hv   c
                     141 fit       th@.c       bnd  I  am goi-iig  @Llo          that  th@,t    @-s    a
                                          and  thoy         go"-  E@                 p:coposE-ti-  in  it.
                     15@
                     161 T---kd i-h@-  r-i@IP ouclit to 'L,@p  to b@,  z-@  good  a
                     17               as  that I-,!-di-,c-y

                                    No,v7, N@p..at have I eLc,,i-ie?T
                                                                      ,,M I-,FLVil-Ig a  l@.ojcjh
                     18
                     19 d c- a ig  -L-Lh          the         o:T       rr-.vici,,,               th@it
                       proccl,-5s       and home do i-,,e zihold o',-:  tlic@    to  deal         that
                     20

                     21 rolc-?
                                    D R.    RG UT, I E S I  think  it  is  an              d,-'Lficult
                     2 2
                       prob).@r,i.  V?e       gone  ztt  i-t  tx,@o @,7cNys. In both  instances,  ,we
                     23
                       have  felt                                 -result.    Th@-,@l-f@  ore IL-,ast
                     241
  (Ace-Federil RCPOftE!rs,  Inc.
                      1in  our expericz-.&cc-t  to       t@,7o
                     251








                           2                  Ori@. of             @s a P"@@,is-ib,..Iity thzi-@ i--hc-
                           3          be  th(i o,-ily  tliii-l,ci  iri the.                               is              good.
                           4                                                          7i 1 1  nc)i- involve the Regi
                               It @-7i-ll bcz,                     :Large.       It i
                           5                             in         Jr.,-i-id of-                         activ,@4-ty     air-'
                           6   -LiAiC,.ar  some                           bz@sc,%d tipoii your                      of those
                           7   ci):cumstcxic@s,  i-iiight                   as        c@,.cuse  for th-C              to g o o ii
                           8   doing  a bad  job                       they  once do.4.ng sc,,-,.iething good i@lith  tle
                           9   kidney                      in @qlzici-i   ca.@e yc)u might  d@@,cid@ no i-natter hotel
                           10  c,;ocd. the               ac-'c-ivit,,,  iv.,@.c-               rc-,sult@-  for  the whol-e
                           11  ):e@iion wi.1.1         rv,@@de                        than better.

                           12
                           13                                                                               z@d E4,nd               is
                           14  des3.gtAled to              the.   nccds   of    t,l-io.    popu)-,,--ti-on    in    the    best
                           15  poFc3-ble            r.,i,@y p-o-v,@ z-i  c-                                        ograli  f or
                                                                         _;ood %,ch3,rle  in a                  p-@

                           16  le@,rnirg h--,,@@! to do                   in @.xi

                           17  ayid Y,-.i-ght be an
                           18                  Thcrc@   a-ronli:   z.,--,iy                           on  I--hz@t.               are
                           19  tli-- Yir@.d    of cvertc N?ou hp-vc@, -co                          ai      E@n       individual
                           20  b    i c-,   Alic', it  is c@.@Fo2.ctly tlill@i.t ',,,ii-i@d of                              the
                           21  Co,-CM14t4-ee,  I  a,,%i                  is            to have  to (ic-al @,7ith.             I  doi-i

                           22          e@ny  shar,,)              for it.

                           23
                           24                   SIST)@IR                                  caii  anticipate.  anotl-itir

   .4ce -  cal Repottels, lric.
                           25               the cox,.sultarit,z,  do not have  to oxc@iiine the project on






                                     i t  vi.si-,'L-, but, c@i-i be con@@-ulted by phone or iTai
                     2                                        ma@--o. a@d               of t'Le
                     3                                               -,@,id what actively C-@,xists
                     4 i.,i        d-Lf'6--,-ent. Zi,,rid I c:z,..n sec-- that- the v@3L).idity of a
                     5 to-chri-F-cEF.1 -r-c-v-i-,-w co-@%16 ba in              those Conditions.
                     6 And I cLri even visualize the conditions.
                     7              DR. l@.2@.r@GUY,.TES The5e                visits  @;,,ill  lIEve  t-.o
                     8i  be on site visio-s.  late are no4(-- goA".ng to accept the paper
                     9   review'.
                     10             DR.                   I.d, that is not @@liat it -,ays.

                                    DR. IIAPGUL-&ES:     It el    I-L I t?

                     12                                            o.
                     13             DR.                  Vl (-'II I I, irt tl-iat c,-Ic-,O, v7e to rlai:-Ilcil
                     14 full ag,--eer,.@-nt because I can't sce just a paper rov4-e@-i of it
                     15 either.    There has got to be             site visit invol%red in tl-.is.
                     16             DR.              7,.s the              cz,,n tell, thcre ticks
                     171 been                  alnourt- of                                       and
                     is@ b r- tN-,Teen var4@oil-s coic.,.,nittc-,e   Council mon,.be.CL@, r@.., @Aps ,
                     19 @,td various people in the field. And it was not iintil-

                                                            C4Sion       IT,,@og
                                                                           't
                                                                             .  of     S@
                     20 Tuo--day there was a fi-nal de                             th c things,
                     21 the thought bz--Lng on i--h(-, F.,bili-Ly to leave a ria4-l volt-.-c. 7@nd   e
                     2 2h4,4ve in liL,,rid somc, tc,,(-,hnical rc.,vieiqs in      i.n c-!(--@ittle F-t th,@
                     23 AS7,,IO meeting %%7hich @,ias con%rened, a rov2.o@ll cor,.l-m4&tt-e on a
                     24 p-oposal for five ri,.er@,bc-rs tliajt-l vere rre,@,en@@ tl,,ere, aaid they

   Ace-Fedei@it Reportors,  Inc.
                     25 discussed it thoroughly, but they had not site visL@-ed the









                                                                 !3 wc)u,@      ty@ fi ca,  c) r not-.
                                       reglon,

                          2                  It i s  ve L-Y 0, j'
                                                                .milar all

                          3  This body       siL'.s  in                          lia,,7ing I-)'Iiy:7,ic&.!-.Iy  clonc-.  to

                          4  region to       site visit.
                          5                  DR. '  PT-J-IL:    Sister   Ann,    I    believe    that    both    OIL    the-.,
                          6  que2L-lions     that have  already began raisc:d and those., that will
                          7  come up,  you really 1-iz,,ve the.                                 d i  n                    e ri
                          8  by   exception   @.!hich    is    as    broad    as    we    coul,d    conceive    it    to    be
                          9  and yet be hal        p-.1-cul.   And   that   is,    i,71icre    the    rxAG,    where    the
                          10 Cl-I.-D  eg-onc@r,,  where  the   DS.rectc,,--   and   his   stE@ff,   or   x@ei,.ere   t-l-ie
                          11                            h@-s  a coi-iccrr.  apart fror@. the acti@al toci-inical
                          12          Of          p ,-c p                                                                  to

                          13            thc- data ai-td to                a
                          14@                IZoii,  the concer4n c@,n be. on any poixit.                       fo-It th@,--e
                          15 %,.,cre  oc:rvtr;-Lon,.  %,;hen  -Lt  would  nol@  be  r..ctc-@csa.-cy  to   ii,.z4l.e   a   full

                          16 site visit beca,,ic.),e o,z- roc-z!r,,.t                   by -.zjtaf-f or

                             7t,-nd v-,,e v, re trying nci--  to bi                                  t -4,nto a
                          17                                                   eN,-eL-y arpl-ic                                C,
                          181 I't'e would               that p@,iost                      wo,,xlcl involved site
                          19 visits,  b-Lit ije wan-@,c-d to be  f:L,@c on the,,',--              But if there
                          20ia   concern by any pir@Ly to t@tis                             p---ocoss that it t-! i-,@-nlt
                          21 ark adequate-,  valid revict@%,,  tlii.,i  coi-c.,-niti-,ce is g4-.vc@,ri -L-he  fLill,
                          22 r.--sl-@nsibi-14-ty for raising that  co,,-Lcorn,                            full
                          23 from the stiff,  and m,:J-,iiig                                                   it so

                          241 dc!sirc-s  to 1--lic' Ccllilc@l.
   Ace -Federal Reporters, Inc.              It doesn't solve it point by point,  bi-it.
                          25                                                                                 tl) a,c  @4-s  the








                                                       r                   7it 'chr@
                     I        ol       @-ihole    ul
                     2                                 ITz,,y L@x,-ise tl-.k:co-agh loce@li- O..c,tior,.s @'-',C'L

                     3     sec-,in(j     'cc)-Lal T).i,c,turc@ eE, the,

                     4
                     5             DR. SCIIIEP.T-,I.S: I aiTt cti@:ious as to why @he device is

                             pok-Mii:t4 rig
                     6 used                the ro-.g-',-on             the kidney project to
                     7 selcct its         techii.-,,cz!,.l     rcercb@;r    I worA--@d        tl-t@.t
                     8 tf v,,e carry @--@t to th-@.             wc, E-,IioulCi allow P,14Ps to
                     9 select          o-,.7n siL-.e             I think thls           the
                     10                     a             if they dc.,;il-'t: like a. tachnica,2.
                     11        me7rbar to be in an                      position to say no.

                     12
                            c @;.rk , t@...C."u jUF4t
                     13                              z-,, Ic    gro,.ip coizicl
                     14  tcschanism i-n ways iqhich I think should not be part of the
                     15 national I.)ol@i-cy.  I doi).It E@ea the,, rei?,son for-li,)vi-rLg thc--,-@t
                     16 ii-il,@tiate t@ic-t.r own technical review @-zhon it should be done, I

                                                                                                 f, ?
                     17. than),,, thro,@,i@h Rl,,,PS. Isn't. ',-hz,.t the responsibility o'L
                     18             DP,. IIAYER,:            before you ansi@7or, let i-@-a
                     19 ait@p2.i'Ly tire                @-(,,@.d it Find F-is I hea,@-d it.
                     20                 is Jay                   th-@t them major
                     21 the burdc,-i of techi-i5.crtl.. revic,,,,7 b,-@longs to those 'local
                     22             who are brought i-n )Dy the rc-gioi-i fro,-i the outside.

                     23 Is tliatnot correct?
                     24             DR. 1,11-@RGUIIES:         is right.
   Ace-Fedeial Rr-,porters,  Inc'   DR. M-KYER:    TlieTi I @i.iilc Lc.@o,,ii,.rd's ciucE-@ti.oii ir, a ver,,,-
                     25i






                                                                                       67



                     pert4ilnent one,

                   2           DR, I,J'ARGIJLIF,,Oj:

                   3 The difficulty we- find              in iri            Your
                   4 suggestion is that we are still trying to maint@in soiie reasor.,z,,'.,'
                   5 balance even in the ca-egorical activities bet@,.,cexi a centrally
                   6 controlled activity and oi-tc- which is locally -Developed.
                   7            You might raise the         question about technical
                   8 review for all activities  in a Regi-onzil I,,Iedical Progrv@m.
                   9 The basic plan for non-kidney activities is the technical
                   10 reviov7 is carried out under the purvi-e-vi of i,],ie local Rec-ri-onal
                   I II@-adical Progr,@ins electing its     specialists and  i-Us  o@,?n

                   12  corf7ultari-ts , its own
                   13           The rc-,zison %,.re liavp- i-Rccl@ E,.n   in t:i-ic klcl--ic-,y
                   14 activity is no more coy,-.pllicated than  the  fact  it  is  almost
                   15 impossible to get tc-.,clin.!-cal revic-@,i by pc-.,cple within the @IP
                   16 without i-iivolv;-Ilg tlio,-(,. l@@'110 be in fact in the p--ojac4--.
                   17i Ari d z-, 2. 1we are really a.i-rling for is to n@l@@kc that
                   18 who  are not actively p@-i:c.,,onally           are -invc-,l,,i@d in the
                   19          And so long as they select ccmp3.@-c-iit Pao,-le,  the
                     rev.@C-NI?   I                              -       -   t,
                   20 individual selection, it would sc@ci,.i to us, is  reasona!Dl-y
                   21 left in the region as @-.t is with all oi-.h-cr -@(-,chiiical-
                   22           DR. SCIIERLIS:  Then you are particulai--              ip
                                                                            ly c),,einpt CJ
                   23 any    technical review.; by this co-Tt,,nittr-,e, arc- you nor--?
                   24             DR. li@qRGULIES: That's right.

  Ace-Fedetal       Reportc-rs, Inc.
                   25           n- R. SCIIRRTIS:  I gt,@ess I h@ive to wrestle with that






                                                                                                      6 8



                          out-              do@@,s,,

                                         Y,,gi,,yT@, iz: Lel-
                      2                                             a
                      3                              @id                                     havc,- )..)cen
                      4at it tiA70  holes in            of                               hav(,- a
                       ff:-(-.Iing @-ze L-re @jettinq a ii- L-Itle hea-,,,y
                      5                                                                Aiid let ro.3
                      6c-,ugger;t i@?e take a 15-ini-nui--e break at this poin't in tivie and

                      7then c@-La back.
                      8                              a rec,,c@.-,s wz-,@ taken.)
                      9              DR.                    'e@c tP-li@ Our seats, please?
                      10             We          1-i,l@.e to cfo bacl,, to p,-ck 'Li,@o      N-@le V,'c!re
                      11 ovi -Lhc- ki-@i,,-.,,c,,,y proposal  and        if there i,s fl2,.,:the@r

                      12                      t:qat.
                      13             Yes r PI'AI I.
                      14             DR. lqlllTE:    It 3.t; i@:ith       clegrc@ of
                      15 1 can  rtal@c- this co:,.-L,-,.cnt              of the fu-t,.ire, but it
                      16  has bccii interacting to              the grz-.dual
                      17   that door on ij-. tl-ie         tli,-it @@ie %ic--e never allai.@zcd to ar.A.iik
                        coffee in these                     @.-o-oms,       shorlc- t4A-i-,n.0 ago,
                      18
                      jgi we were to)-d        -co loo,!-. z-.,.t P2:oDc-,,;tst tod,@-y x,7@- P,,,'e
                      20 frO,-ft s,'cokS-nci,.   I'xd &n v.-'KeT,7 of the nc,,e; guid,@-I,-xic-s, it
                      21 W-A.11 b--                -&c)," u.@,. to rqa)@e any deciF;3.o-.-iF, in the iiee,,r

                      22 f utll)fe -
                      23              1 hoy)e that the remaining iieinbers of the            co,,Pai,4.ttoe
                      241 can be

   Ace-Ff,,doial  Repottr--ts,  Inc
                                      DR.                 It is C,-Yrai@-,i'Patic)ii,, thE,,Ic is what it
                      25







                    I             -T ii nicd to                                    -ccnal

                    2  are         to dr@,@@7 f

                    3  the         s, are @o
                    4  ends up in a sen-le of z:i k-@.Y.@d of rou,@id rol)bixi in xqliich
                    5  strip persoi-is are                            at them.     And I
                    6  that becai-ir@o tlic@,n it would b@,-in(j      re@tl:Lty to the qLi       o n
                    7  if, -'Lndeed, the rogjot.-I cc-Lii        i.t--  owi-i             nnd
                    8  there are p2-e--ious few of th--i-n, wait li.be.-ty is this in the

                    9  final aiialys4ls?
                    10                            Do@s someone have inforr@iation? Ed, do

                    11 'You h@%ic-.              0,
                                                     4 t, ?


                    12             Did rou @,12.         tlic-.,
    @le                                 .1
                    13             DR.

                    1 4of                v,,,- would kcir@p                           wo-

                    15 kr@-ci? available! h--r,- to acs4.s@f-- the
                    16             At       t-j'_n-,o tht-,@.-- decision i,.7as made to       i-n
                    17 this dirc-ctiol.,i., @,,C-!     oi-it rer-uesl--s to                   55
                    18 diflr(-,.rent e@:n-,irts in tlic- field w(@, felt could bc- of use in     t)-i5
                    1 9activity.     I don't         e.,.ac'i:!-y how iiizr.nl, rcLpor,@dc-C-., y,@@t, l@u,'-
                    20                                   a        of          50

                    21 v..,ho could b--- used by the                 th-c-         p-@,-,ess
                                   I wotild li)re to address @his issue of tl-i@-
                    22
                    23 a          Ir,0170 since il@,     tY,-e ct),'k--,joct upon .,ih3.ch the coffee
                    24 br@,cL",@ w,-&r, taken.' Ijt-. is    of                 tl-.c coffee b,-rO. @-k

  rkce-Fe(lefal Repottefs,  Inc.
                    251 Has tal,,en during th,@@ Ir.,d.,,ic-y d-i.f;cuss).on. I assume that a





                                                                                    70



                  1  blr.,ddr-:r bcc-Elr, is     to-O.
                  2           The issil-a of who does the tcr-hniCZ41          i3 Ol-,e
                  3  that has L@c,-@n of Fnajor concern. The point tl,@at Dr.
                  4  just raised about the nu,-,,bar of ccnsultOrts was the reason that
                  5  prompted us to insist upon there bc@ing pcoi-)le frc!,a outo-i-ei@-
                  6  the region.  Bc^ause if you can   4,Tagine within any or@,a Flip
                  7  the total nur@@.)cr of consultants that coLild be zivciil,2blc--, and
                  8  would have the competency to do the kind of review w-e a@-e
                  9  loo)@ing for is such that they almost undoubtedly will be
                  10  involved in the projc-cts initially.
                  11 -         DR. l@5P@YER:  Or if they aren't, were c@-icor-,ied al@out

                  12 it.
                  13'          DR.            'L'hat's        Or if t-Yicy     not, it
                  14 is bec@-use they a-.re from -nol@-ho),- i,,ed4-cal school and have
                  15 the scratch-c@.ch-ot,'.z-c-rls-]:)ack z,.pl?---oach.

                                                            about was
                  16           So %.@h@:,.t we were concern                       g to
                  1 7assure there will not be a casual or cavalier ci-)rroacil to tl-i.-@
                  181 technical rev3.c;.,v7.  So the decision was made to         upon
                  1 9t-Tiree people from outside the region.
                  20           Noi-i, it is impossible for us to keel?  tip  with  who
                  21 might qualify on a Yr@on+.!-i'Ly be-,,,is or semiannual basis.  And th4---,
                  22 was the reason why there was the freedom for the region to co-xa
                  23 to us and sciy, "I.!ay we constitute-! our review committee from
                  24 sorr,,@o@ne ot--",,or than those on l,otir @,st?"

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




                                                                                              71



                                                                 fly havc. not-. i?rOPOs""71

                     2 rn g       0   t 'I -0 C),,,,'
                                  Tlle cr4 toria vje wov,,.Io                        is  tllFt  it
                     3

                                                                                              if
                     4 ba -,omeone Nqho has                           in the ar,@       -C
                     5 it x,.,Ould be a Pcdiatric nephr-ology -L-YT@le Of                  Ol-e
                     6 dealing wi,th children orL].Y, ): lqOu.Ld L-,e 'v'CrY distr,--sEC-d --f
                     7 technical review were done only by                      treating     adults
                     8 only bc-caLiEe the px,-ob2.eyr.,.3 of children  with  k4,dney  disease  are
                     9 diffcArc--.-,-4t  those of Courts with renal                   So      do
                     101 have the righ4@- to say that this i5 not on adequate revi--,.4


                     12            1IC, also leave z,@ddcd i-,Iic
                     13'        be        to       iia@L-ioria.L -Lc@@;,:!I, be        fo.--
                     14 perusal ei4--her by tia.4.s group o@- advisory cov"nc4@l or by      staff.   i
                                             limit aga4                                              I
                       This will tend to                @n peop';..e gi%ring a very
                     15
                     16          I @,ioiilcl thin@..  ilrid it is coi-iceivabl  Eo.-ca pcio-olo
                     17 but z?,gain the nurc,..ber of            co,.Eul-tants I-)cing, %s T
                     18 said, in the 50 to 70 rz,,ncj,@, the number of potontiEtL
                     19 being in a                     posr,-&bly if each reg4-on had
                     20 appli-ca--.ion:n, irL, again I .,joul(-' Y@c, su-):priccd if
                     21 is potential applicant f.7@-om            A would gross  ovc-,-,:  a  poor
                     22 ap      ti.on of Region B bec,-,usc@ Yte in tu--r, is going to 1-@)O
                         .pl--A-ca
                     23 submitting cai applic:at4-cn                       the line.     So I  thin'@-
                                                               g activitv.
                     24 it @"ill  be            Of  a  POlicili

   Ace-Federal lcpoitets,  Iric.
                     25             Of  the  rex;,icw.,;  that    come in  so  far  since  the





                                                                                 72



                1   @-io,-d began to 1-c@ o,.,,t. r-)f @@;hc@
                                                             I  W,.IS i..n

                2  minutes last Poland of so-  of                   -t v,@is goiii@-4 to
                3  occur -- I ha%re been            that                       li@,@,d
                4   started lo,--ally and -"Iicy were People   N@iithin the region,
                5   there have bc.-en soT'Vle rLi.-,.irly gr@Avc! cue-stionE, rai.Eed about
                6   ad@aquacy o@'-   of @.c-           that have come :Ln by reo,?I,e
                7   i@7ithin the area sinc@-   ),.no-,@7 is going to. be a written

                8   revieiq.
                9             The staf'L role in preparing               that cor,,---
                10  to you o,- to tile         counc.i-'-   be to a,.@surs- th@t tl-ie-@c.,
                    ,has bcen                   not    sz--y k,-@ftcther the Stay is ric-1.


                12  O"
                13            In the various           o,-' tl-ie @bcuma.--it wc-@t
                14, out, that particular E-:O;-Itenca  lo,-r-t out under    staff
                151                  Bu,,- in ti@o of Ic-li  appl4c@tionE,, tl-.-at arc goirc,-
                                                       e



                16
                    to be discussed this Y;.-.orn",ng, @.c loca.1
                    rec,---.@Tit;.ended         in t--h,,@ apl).-I.icFztion, the RI.,!P d4d not
                17                                              .1             -
                18  lic-@-d those               and fo@,,,@iarded the applicaL-io.-i
                19  It j,s our                t-.ha-L tt-tc,,se be d4-s@.pp--oved.
                20            Wd sc,-- our i:cle as bc-ir.-g a N,7,itch.Ciog to aFE:u,-e flat
                21  the I.>rccc-ss h,@,,r, gonc, ori a:3 d(-@fii@cd.
                              DR. I,,'AYEI@: Yo@z a--e go--;i-ig L-.o fc,3-31 free to o-,ilv
                22  1                                                                 d

                                    0-Ti
                23  On P"'Ocesc-, net
                24            DR.           Contcnt i.f it is cli-spara-@ from the
  Ace-Fedeial   Repoiters,   Inc. national priority. Tlij.s iE; one oth,-)- arL-.@i, tharil@- you, that 1
                25









                        h@.cl fc)rgo'-I.'Nn tc)
                                                                    bcgi,.i,ning of

                        2I have lost rci,,, copy her(@      on the           page,    @,e    sentence
                        3iind(,,,..r' C-LirrC@rLt RI@',@PS                   ki(7,,Y,.ey          it
                        4sort  of  casualllr  refers  to  o@   p   nel   o'L   regional   authorities.
                        5We have t@,,,o plans, and we doxilt  know  %,.,Iii.ch  is  going  to  h@,v,@-
                        6to go  into effect b--cause there are changing decisions.
                        71          Kidlicy is no dif'-crent frori the other IU.IP
                        81 A,-- one time,, x.ie were as),@,@ci to si.,JDmit scene recoiT@-a3ndations for
                        9c.@xpansi.on of Jcidnev aci--4i.@,ities . If -Lhis, was to occurs part of
                                  Id requ4-re the consL@.itu@@.'A.on of a formal adviso,,7y
                        10 this @,iou
                        I Ii,group a-dv.i-@,oL-y to Dr.          on kicLicy disec@@,.7,e N@.,hicli iqoii-l-d
                        12                                       tc>          re p r i 0  t i,
                      .13 that does       occur, we w.14.11                          a  gro,@-p  of
                        14 authorities to corra in and si:@cfcl!.ast priczities to look a'.- how
                        15 well the regionalization of                                  is occi,,--cr4-rg
                        16                                      that ,;.s l@,.-iit       -r.   7@-rid
                        17@ their finOin@-F,      he               to $the  region so they
                        181 thcm, the P-,@IG cliai.%nnz,-ii and th,3 -consult@.-,it Lhis !;-St of
                        i                so        th@,, go into e. region tl@,,Ly  N-ii-11  hovc-,
                        19 so,@Tis-i@-hing to judge by.
                        20i
                        21           In tu@n, then it              Icre,  if  staff   .1co'@s   end
                        sees if i-.seeras to I)e                the             thi.F; @@7ould I)--
                        22          L-                                                                     @ I
                        of the o--casions wc- i,.Toiii.d bring i,'- to -,rour attention and the
                        23
                        7idvisory Couiicil.'s                    It doc,,s not         to fit into
                        24
   /Ace-Fedc,@rEit   Rc-poiters,    Inc. the nc,,cds as dc!teriiii_rclcl by thin c)iztsi(I-e groul.) of  e.,,tperts. So
                        251






                                                                                                                             74



                               we il!oul-.d                                 in  -chain  coi'!,"(2xtr

                                                                                                                          op
                             2                 DTZ.                     rr,,O       01-10 MOI-cs, all@-I  -T- @'@ill

                             3 AyLd thrt       is  the                      -.nd  -Lhis  i.,@   ai%   i---sua I was
                             4 to gat out but do4-ng it                          br-,fc@rL,  tlic-.,  bi:eok, let's  see  if
                             5   c,-,.n do  it b-@ttc-- afte,@@:,           eboLiL-  -',---he  ',-s@-ue- of rc--gionali-z;--@tion

                             6
                             7                 one cf the tli;  gs  I  co@,nrvenl@,'.ed on  is -,-t cood recyioii
                             8 that  is goi..,-Ig -chl-ough thrt process or a poor regi,o,.l tlia-L,
                             9 isn't  and a k4.C-ir.--y prograia that  is.   And wy p:coblc--,m i-c,  Alto is
                             10I                tl,.Pt                             proceeds?   Iii oi:l-.er word!,i,  you
                             11 can heard                                          coi,-,,@ztei-Lce  in the iqorld across

                             12                         one-,,                     ai:o- no'--                         -"i-t a


                             13
                             14,               NOV7r  I guess  I ncr-@d to hr-tve  -t feel  for i.,,ho .4.s  looki-1.1c;
                             15 at threat.     kid  if 1  @,m not oi-7.t                 to samp'Le  that and if  4:Ji---t

                             16 i s  v@ p  t   of -,@-he                           of  '#--h3.r,
                             171 has go-'--  -L--lo b-,!  o-,it there  t@        E@bo-al@-  -chat issiLic.   Or  i-.s  il@-
                             181 z,,                      of                    ;.-oviev;?   Who has  tha4L-.  ros,;)onsi-
                             191 bili
                             20                                     T'I'ic, bc@.-,i(- rc!-.Ponsibility  for

                             21 tion  rc,-ts  in            li@-,,.ndq  o@
                                                                                     -Tio,.ial Advisory ctroui:y  -,i-i

                             22 each            1,@c Scale 01.11- staff :Cole,        T,.AY staff sees  its rol@e,
                             23 hr@rc@- It@-.o a-gain          bQ.1-iiii(I            T@,3 you              the):c          the
                             241 reg-ula--  rovic@@,7                                                   7 process,  w)i.ich

    Ace-Fedei@it   Reportcrs,   Inc
                             2                                       'C.0  loc)l,,               issues  of
                             5 90@-s on









                                                                         -y sti
                                             r                      B u      -kf f
                   ac
                  2                                 iy,, loc.,ki
                                                           f,-v point in time cve--y
                  3
                  4         in                         vcc,,-Iss to a kiC@i,.,-,y floi-,,
                  5                                           to wat---hdog the
                  6                 and again bririg it to 'che z@tL@ention of rev'ic@,7
                  7  corLro@itte and co,@ncil if it is not followed,
                  8          DR. 1,9@,YER:  Sc) is ti@ia-Ic of t(--chnical revie@q or
                  9  is that pa.--t-.o f staff effort?  In otlier ii6rds, I feel free
                  10  to cofLTPent abomt the reqionctl @,dvisory gronp locally in te:clrs
                  I Iof how err-- they fvnctionj'-ng iii teLT@,.s of

                  12
                  13                I          I       -;@i i s i,@,      that the @-@3
                  14  is a possi-bS.Iiiy t)),at tlie:L,t-- is go.:)d       in !-.ichiev
                  15  bad regional.izetio,.i IC.,IP. I wait to     is loo,ciiig at

                  16
                  17          DR.           I am gcing to bring an cyp@ic.,plL- Of
                  18 to you vilicn i@,,e get into tlle E-,CCi:[,4C E),@ppliCp,-Lion@ beCaU,.S;e
                  19 have a region in k4h3..ch tl-,c,, kir,',-Pcy program j.-, b,@ccy,,iing

                                                            4
                                  :,.rd               to fi-.nl.,--h the p@-oc-,ess.  !,lid
                  20 reglOila
                  21 it 4-s not tl)e         I:U,.IP a         A-rid .@ie ar@,-
                    that to you foy-- adv@i@.ce @ii,ld        coni.,Ten4t--s, t-l-iis
                  22                               i                                 -
                  231         DR.          llolle O.K.
   0              24          DR. P2%11@L:  Bill, Ic-ilt-I Tiia try ci stateroeiit. T.
  Ace-Fedefal Repoiter,s,  C.
                    this  will be a continuing staff co:i--crn becuuse it is one of





                                                                                     7 6




                  I     bac,,.4c
                                   -3 0- l@'-S j,.5: tc,-) I)rorro-c-.


                  2                 for
                  3  the local RMP, bu,c. -'t:-Iiis @,@ould. b,- a tli@t -@-La'A"f wol)-I,,l
                  4  !co],-ling ac, aid comc@:3 ui-Ldcr tlilc,% point of if the-,, F)i-)-ector,
                  5  has a         apart from the I-ec-hnical          of      projac-.-,
                  6  it comes to this corc@iittee or if anyone (>n this
                  7  such a concern.   So       I don't thir@',@ if-, is @@-nl-loiiited i-o
                  8  ju,-lt staff.  But certainly it @e@,ould be a --esponsibil-ity  of
                  9  c;tv,,ff to   at  tj,.-'Ls and     iiifori-i;,-%-ion to thic@
                  10           DR. 1,L7V.ZER: Bill, yot,@ had a cc;,T@-a@nt?
                  11           DR.             Le-c.'s tizlze a vr-,r-y spcci-4'.4.c- exarr,.?Ie,
                  12 o4nc-,. you             on            Ard

                -13           Va..I@l@y.
                               Going back to Bill Tia,,,er's qv
                  1 4                                           estion, that
                  1 5tion 1,@as not          by the RAG.   There are good fac.i.lit4-ct-i
                  1 6across tlze st--eect froya each             don'-, need  4;o  bo
                  1 71,7ho does have the responsib.;.].".t-,17 fo-- lc4o)@ii-ig a.-c -'%-.Iic!
                  18, Vallc@.y?  Is that E@upp@se-d to b,@ the RIIG?  P"id if sot
                  19@ do--sn't N.,,ork.
                  20            That is       Bill is really asking in a iqay.
                                DR. IIARC-U.Ch!ES: T-h,-s is a very key quc-@stioi-i. It
                  21
                  22 iiivolvc-s the %.ihole cl),ancTc- in @3tructtirl-,
                  23            one of the thii,,cTei th@it @.ie lia%ro done in the process o@

                     changing
                  24           -1-h-a revic@,,? c@ cle f,--op, four to thr--a is free a

  Ace   -Federal    Reporters. Inc.
                  25 1 considerable amount of staff timo froi-a ilic         pro@,,,@SCIY z:ind





                                                                                       7





                                      n
                  2           The          -L-o'yo,,ir        is       is V.I'l
                  3  respoi-isib4.1-iA,--y of  to                           e). joeii,d
                  4 unon technical renologi-s-l@:s to do.  I        it, is  quite  clear
                  5 a man can loole. @.t         oz no,'@L-          r
                  6 can. be done effectiN7ely,  7ind he rii,,-,y try hi.s best to be

                  7 regional irt.-'Lr.6--d E.-nd i-,i@,y nr-,,c. bc-,,
                  8            The rc;.@rt of it                no'$-- for tl-@e iio,-rLent
                  9 call ted-in,-ca.L         but call reg.4.onali,zation revienq, is

                                                      lo,@
                  I 0:r:ometi-4ing wci, ch siv..f f                 Tlic,,%  x-ii-11 b-. in
                  11 @--E,@gion     tl,.c-i apl.).I.2'.Cation ip, in, it is in.   @rd

                  12
                  .13                                  d-oiie -.n L!17,L--
                  14           DR.                   ir, the role the cor,-T-iittee p"-;@:,ys'?
                  15 1       we Zile b@,cl@ to      question oi@e moa-e t4-rt,.e.
                  16           DI).                              reVie@,7.
                  17           DR.                d                rcvi-c-@,@i  as   you   have
                  18 lust defii-i,-@d it. clo I       succ- i,,Tiiat role them

                    I                      I,,Iay     tho"e
                  19 Plays i@L it C
                  20            DII. kIlilIG13L.'.r:.S: Yot),, 11-Iiicij,  ;j ago
                  21 N-Ivs sO,@L-:3 mention made of               Pnd  I  i-iou).d  li-1,Ie  to
                  22 rec@pond. cin- -chat b-,catise i-liot is onto of _-er-.sons we @.re
                  23             the         of i.,Tom@-in oi-i i:ho. review co.@Tlitteo,. so N@,,e

                  24 -vion It ):>c- too (Ir@

  Ace - Fedefal Pepotters, Inc.
                                That real.ly isn't a very good    N-joi.-d you iisecl bc-f,-)re,
                  25





                                                                                78



                             DR.          yol@             u C.,
                                                              d          r, n .  T, I z,.


                  2gocs either sax.

                  3          DR. I.IPRGtf--.II;S.


                  4little better.

                  5           (Laughtey.-.)
                  6          There iz no evadii@,g the f act flat wh(,,i-i you are
                  7  running aprogl-am as we cre which is dealing 95 percent of tl-lin-
                  8@                                     and. the Cray in %-7hiclji @ey
                  9fun
                     action. that you cz,,nriot @@t tire c;@@                 p
                                                          tim,@- u@e th(@, s
                  10 on wl.'I@it is I                Project l-,j..n@l of activity.
                  11 1,7-@ncl there is l@ittle doul:)'--- bti-'%-- th,@t the rovici@,,, committee, srole
                  12                   0.0-,s  ric),L-1 liz-zvc-             P@.,ad the-

                                    it e       @cl-       a:L
                                        o-s v.,-

                  14        and       c-)-ttcnAc.--on N.,@1),icli i,'L, cji-.v--s to
                  15 Medical Progrzns.  Zind i,7c-, leave b(@,,:--n say@.,rg tl,.at iiow fo;r

                  16t
                  17          @%lhz,,t we a,.-e   you to do is to look ztt the
                  18                    of the           Medi.cal
                  Ig             but not asll yours,,-Ives to be techn5.cal rcvici@
                    people and not: ask             to I)c- fi,;cz,.l    in
                  20
                  21 viha@-- t-l-ic actual bL%dg,-atz,, Ic-.,val be.
                  22          DR. 1.2.-.YI.7,R: l,c:,oni)-d,

                                   S Clt II I-a, T S -.
                  23          T) R.           I cjuc@ss having --to,@-tc,.d the p@oblera
                  24 thi@, @'ar as trip,         of- cin,@,.ul-@.@,nts, I  V-0-Lil-d to

   Ace-Fedcral Pepoftets,  Inc.
                  25 pursue that further.





                                                                                                   7




                                                                      to Y'Oup
                                                                                 Dr.


                      2sce no rca@:cri   'o@


                      3
                                                      rry,         i yc-u h@znd him                  one?
                      4             DIZ. SCliEIU-,IS:                        to yo,.,,r                to
                      5  @l-hy the regioii-O should Select-. -chci4-r oi@ii consulti@l-LL-.s, I ce@illlt--
                      6  reality di,--cc-.:cn tj-ie     you made.   Tho. rt-are          tha@,'@- tb,@,
                      7  IJI-sl@-s        tILey eli@ii-Lge loci,-,Ily ar; wi?ll.  ILatic,,nally. Slid
                      81 x,.,ould th--i.i).!-, if a @-,c@c,qnical review is ii-ideed to co;-,ie to t@r,
                      9@iith all of ill--s finality, as we have bxl-en told, that I would
                      I 0-iivch prefer t@oal-- the technical review be done by consulterit-s
                      11 N,711 r"re       selec@tc@,d          I ly
                      12             1 s-a@ 11'10                                         ciri the,
                    .13          on                                                           if

                      1 4
                      1 5Faly at all?     I II o IC!,. e r w od r;, i t g. a C, s f r o m h ct. o t ho.
                      1 6A-fi.,,r,-Ic;o@y cclu-ici-lf is it       that x,.-e h,,;,ve rLil-Adc-. sono
                      17 upon it or do Fire          sort    f i.g.-nol-e  c-@ fact tlic-@re is a

                      18,
                      19             The po.4.n"-- I art-I goir,@9' to      ic, if @,;c. leave zny
                      20i                       on thir,, I            fi,rcl it iXpo,.3 4ble to    )-.q al,@ e
                      2 1 uch acti-rn            the,.,                Ekye ix,.(I@ed @PT.;oW,'-nted f -Cm
                      22 tire. national of ice and riot                  lo,-ally.     I %,70uld
                      23 -chat poin,-- P,,i-,--sucd 41,n sorn detail,   I have Father strong
                      24 feelings @.bout it, mine! I -v?oul.(I, life to c:!i-chv,,r hz,@,-ve. th(,@iii

   f@ce-Fed.Lial  Rcporters,  Inc.
                      25 by your co=.,Icn@-s or cc@r,@,y it -#-curt,her to in aclci-a-t by tlio-




                                                                                so








                                                                          s
                  21


                                       i:,o         is an       tistc,,,ncy in 1,;h@'-
                  4
                  5     heard. @,@out               for the loc@tl Pc@01?10 to E-elc'ct
                  6technical @.eview locally and ya.- have them approve SOT.-- ow
                  7@t natiol@l@l. Thc-,re             constraints to he Placrd
                  8on                                  Th--rc are fe@i people to be
                  9called "pDn,  Th(@y       to be e>cpert,   would         not c.,nly
                  10 in -',--h(--              of                     but aloo
                  11 -),-U:Ll@y a-'C.         also             P,-gionzil Iiedi.cal
                  12                                                    sitc- vl,-si,-Lci@---@
                  131     o                       -'co                  0, SiTnplo-
                  14 technical @-sp,,Bcts of tIl.e rcnal
                  15          Lnd i--hc-- rol-.,.cy  )-,,i  mc,,2:c
                  16                to ric if-. rogiolis could   fo-"       to 'r-,z
                  17 p2.@@@cc-d oil i,.   v-,anel and tILus the         pc,.nel
                  1811 bv            if yot,. like, 'Lrorp, regions of            th@-"!7
                  19 i@.?oul.d  to          their     the tcchniczy.1-
                  20 picked nationally ai,,cl. s,.jrit -Lo zt reg@.or,.. This @,,Tctild !De zi
                                po),3.cy, a',-,    P-nd -vro-ti)-d rci@jc--t them clesi:ccri z,@ s
                  21

                  2 2I have heard them
                  23           Pnd I belie@Fe  @s            lierc@, it i.,; incL-rici.rtor-t
   0              24. rA-t  sortl.,.@  poi-nt.  . So  1for
  Ace-Fedr,-tal  i@epoiters,  itic
                  251          Agz,,in, 1 V70uld, li)fe romr-,body to     to     the
                  I
                  I








                                                                                  I)Y
                      1f-,econd


                      2,since kidney
                                       posais are K@-viowed
                      3le-,rel," axid finally, "Kich-ic-@y                    s    ":,.el l@)Y
                      4r,,I.Ips ill relation to natio,--ial          7ziid I N,70uld lil@e to
                      5kro@,., by whorit th,7-t is to b-@ d,,,,ia.
                      6        DR. l@A-NYE.R:  Tt-io issiAes. @-tls           the

                      7of the selection of the
                      8         I crucs,,- the conc@-.jn-i  I rm I-,sar3.ng iE-, a corr--,-ra
                      9tl-.at is expressed on the              of           the
                      10 so to Sp--akt if the selection is iiade by       individual group.
                      11 -1 ani no+- sure 1-io@q i-rLuch ciierclr is involved in settipg 15,P
                      12     of dic       o@,
                                       4 Cl.,                               a .   I't
                                      a@            and
                      14 seeirL to re that tl7iat is not too g::,@at a process, @,,-id it
                      15 teJ',cs away I am not say,@-iLg     i,t will o,-- i-iill
                      16 it -- at least it      Away i-@h@t                            is
                      17 going -,o be raised by pcopl.-c, I tli4-i-ilz,         about

                      18 this area.
                      19         DR.                                  th tlizxt if      4-s
                      2 C) Dr. -tia3-g-,ilic@@' decision. It v;oul.(7i not be @i rvt,-ijo-,-- to d-)
                      21 v.,hai-- Dr. Scl-tynidt sugoestud,
                      22         DR. I-'j.ARGULIES: I tl-iiiil-. this is zi very iriterc@L-@,tiylg
                      and reasonF2)-33,.(-, idea.  Ai,.d if i-t cypresses @.ihit the re-,iiew
                      23
    0                                 d, PrO-:r-E!r, we   certainly b):"Ln-g i-';iat
                      24 cOr,-Ynittee wOul

   Ace-Fc,defat   Repofter@,    Inc.
                      25 tion to the council and di-scu!7,s it with thepi. I don I t scc- it





                                                                                 82




                                                                                ts
                                                                       YOIlr-
                   F, to C)                               Iran d I @l 't

                 2 a@e


                 3

                 4                                   f
                 5                     E,,o       ha@rc,. @ri opinion rendered by
                 6 Coancil or,. thokl- quc-'@               for us to do the@t.
                 7 B@-caur3c-, T @7jo-old 1-11,1@,r@, -"--o qiic!,,;tion that sp@c-,.--
                 8 point to tlia lac-@"I-- tlxa4--          po-lit is oi-ic manifc,-is;-_a-
                 9 -?c,.4-on of c4 iL,licYt q'oa                 w,-- should bo
                 I 0N-7,4-th .P,.nd th&4-- is    along the lire w-. h@.-.@ye got to
                 11                        pt-, o--F- r-@Z@.G and local! revi,-,w zird

                 2                                        of- a

                                                                4-1
                                                     .rz n c
                                                         ; cj u @r o -.,i

                 14 you @-b.-n4-t h,-@s P.FTG        1-ha-'%- Le-ids to reprove
                 15                                      -I.Lrg-c-r decision, aboli-L-
                 16                      iii the                      but the .lord

                                                              -ik 1--h@t
                 17 "cmascula-,-;On"ss ve-Y                                     is
                   being          from                   aci-i-vitics. 7--nd I
                 18
                 19 @,7hr-,thor anyIDo,,-@,y is                      it
                 20              n@.Melcio-,, face).css 1.)c!oplo vl@ho c@,@-c cal.led vague.I
                 21          Mz@,ybe vie ought to dispose of thaws qucstioxi f.4.rsl--f
                 22       d then get to  the largCr qUeSt4on tl-iat I tliint'. is (.I
                  ILc-n ,an
                 23 vcll ry 14-.nipo@tant part of @.t.
                 24           DR. I,,IAYER: Viould sc@itteone cz:irc! to a riotio@l

  Ace -Fedrral r%epo,,ters, Inc.
                 25 relativ-e to -- I gather the key issucs are that the e>,@pl-rts






                                                                                           8 3





                                         the
                     2lcvcl be salecteci   y                          tire

                     3is that the es:@lence of it?

                     4           DR. SCHT@PI,!S:   YCE;.
                     5             N..,ould     tha'(- -@t(3m 2 or, pz,@,ge 3 be altered as

                     6follo@ls:
                     7                                   )?.i.-cl:),--bly it is

                     8to Cou,,ic."@l, th@it ax:-,,,
                     9           DP,. SCFEll,'r.!S.- Ye-q, to Cooy4cil bl-, alv-_ered @-ks
                     10 That the technic@.1  revic@w       mi@c--L I-),@ cc)mpr.@-@,-,Cd of a-',-
                     11                                          thc- geo(@x-ei)hic are-c-
                     12 se-,-,vad b-,,r t'Lle.                      -'co

                     131 r@', P,13 .
                     14i         1-@ thc@@.t-c- -t zE-,corid, li-o -Lhzit?

                     15          DR. TIIUP,1'2i.114:

                                  DR. l@,YEr-,:
                     1 6                                     c v. s

                     17

                     181          All those in 'Lavor?

                     1 9          (Cho@uo of Lyos.)

                     2 0          0

                     2 1          (No

                     22           O.K.
                     23           DR.              At tlic-,,    of being child
                     24 coul-d T ask                 to say o,ic                    our

   Ace-Fedeial Repo@teis, Iric.
                     25 ):espon,.ibility is.  Becac,.se I (lidn't catch it @,.,hen it        by.





                                                                                                                                                                        8 4



                                                                                                                                                    thil@


                                                                                                                                           s i,,,i c    i t           a
                                                             ):C-v

                                                                                                                                                    .Itioll i'lli@L.
                                     3 tcr-linica.-'L                          it                                               Y01:1
                                                                                                                                the                                        is
                                     4 a ki@-i'@ly                        hFi!;
                                                                                                                             --es @,,Thich                   daE-c-,     4b
                                                                                                                                                                               d
                                                                                                                     or.
                                     5 i-hcAt it                                          Y'-F                            ii,-
                                     6 in the wry tlia4l- Dr. H41-ni-@.lan laid                               thoyi okii: and wl-.ic2l go                                  to
                                                                                                                              t-o liE,,v,-- a national
                                                                                                              c,
                                                                                      '14 c
                                     7
                                     8 ne-%;iork of kieney dialysis                                                     if all the tc-chrica-1
                                     9 requiren,                     al"e icet        Build the P,@gioxial.                                                     ic, a
                                                                                                    b,@-i).g  Ico your                                      t-he! f
                                     101 gooc'@, sojnd rx7og,
                                     I  thz,,t the                                             aspects Fire,                                       here rc@ally
                                     12 iLn          Badly  I                                                                C)."l
                                     1 3                                                                                                                  o--        c n
                                     14 tlic@-re is a ch@@2.                                  oh is E),@oi:kglit up zt a-ny p- oint                              iii this
                                     15 r@,-icje. of                                   -'L-4LI*n YOU do co,-"t!2 ill-'%--o act--ion.
                                                               DR.                                                           by                           this
                                     16


                                     17

                                     18                        DR.
                                     I 9 0 x c c-        o r,  .               is i.rt t.,Iio
                                     20                            R.                                       -,ci---7-ically  states  O-                                 ii. &, c@
                                                               D                                 I t  L.@                                                  p L-. g,@  I,;'
                                         it is                 4                                                      f c): @,!Illj.ch trip, I'@7@Gp CL-ILP
                                     21
                                     22                                    Or                                                               in(fil-c@,.tcid a
                                     23                                                                            merit@-s of the                                     t-he
                                     24   P,"@PS                                           \,fill  be  z,@@s3@ed  to                        a.

     Ace-Fedetat   RcV)ottf,[s,   Inc.
                                     251                        So  since  -echni.cal  if;  rLoL'.  clearly  de                                  f4ned,          I  would






                        1                        very                    el,-,fi.nitions- of ,-hot: t--c-@,zm
                                                                c


                        2as f @ir  Eis             -in
                        31             DR.                   I.,c, %@ioule). ttiir,-k     probably
                        4                                            to d. b@-itrz-,          one  foi:i-i   of
                        5             or.  arcitlic-)f  i-s  biatt(@r,  but  yoli  cortfi.nly   want   to   get
                        0into ti-tc.@              of whc-t-l-iE!,r-  wl-lat  ic-  be@-.ng  prcposcd  is  going

                        7to          the rec,ion@,11

                        81             DR. 112,YER:     Jerry.
                                       DR,,  BTSSON:      PerliF,..ps,  thc.,Yi, if we d.4',@r.,@osed of ieiat,
                        91
                        10 @..le cz@.n ce-L- to i-l-ic larc
                                                        7c@r quc,-stio,-,i of                     Z',Pd it is
                        11                  PI-,.i,l,  that  at  oii--  1)):Calrf  I  used   practically   @,,e
                        12                                                                   ;Iunct.-c-.YN, of

                        3                                  C-L) T. Su-Is,,;
                        14 of this carimit"--c!c that oul- thoughts are not too Lear aparf@-,
                        15              I i,,-oulci like- to                                if this is

                        16    appr--Priz@to ti.ro,-cA.
                        1 7             DR. l@-17@YER:   Could I sligge!%t,      Jerry      Alat thl--,   3
                        181 a major, broad issue wh.'.ch I thinl,. is going to load,
                        19 should lead,  to half wi licur or nio@c, of discussion.
                        20 1 wo-a'Ld li,ke I-o dc) is tc,,         fl.c)-g it,  sac-- h@@,, i.-7e are

                                                                             c                 an
                        21 in          of tii-re,  in t,@,r     of              our go@i.1s,      d i@l-i@,n c@@,:a
                        22 back to itt  if I cciild.
                        23               DR. DESSOIVI:     Srrc,,
                        24               DR. I-,,'P@YE R: To c,,,ct @i very re,-tl red @2,ag on the agenda

    Ace Fedcral, Repotteis, Inc.
                        25  to de  I @,7j,th it.    ]3ecaLi.,,,-a I tlillnl-l it is an  irtport-.ant  isf-,Ile.





                                                                                                                8 G





                                                        yoj

                       2              and I               Jeff.

                       3  in                       that                                        are

                       4  concernG,  and 1        think th-@,y or@ght, to
                       5                                              on      @:cnal
                       6                                      D    Schriid-@ l').c4d raif7.c-Ck anothc-.-..-
                       7   that @.-;a@i                    d c@@   pecrc, I.,,  -cl-,,e r-coc,-id
                       8   P@lid        i@t v,,arj refcrriiig      o        t)ie@ fact thz@@- o--h,@ir            of
                       9   the                              axe           F@,c     a who)i.e, send considered.
                       10   fn o@,-.hcr                                    -tiry cne of tho,- on-0-5            o,.rc
                       1 1 1 -here                                       a-@ a who]-c- , bu-k-- thc,             is

                               C,   c- u
                       12                                                                                  th,,)sc-;

                       13                                to
                       14                 Th@; ,sectc,@.id                          to tl-i@
                       15  to prcvant      hE,.-,.vii-ig z@n                        is technically
                       16                              in bv a             but docs lici-@
                           goal- ol                                                                 t-he co@ntry
                       17,
                          1

                       19                                              c.-,-- c-,   s
                       20                 it I,.'OtllCl  !7Cein        Ic-lic regions tho.@il-- r3.o not
                          1
                       21   these.,                      -Proud        Ei           prio)-i-ty th@n a
                       22                fo)--                in    v.             that al.rc@,@@dy lir@zs
                       23                                                                 ir, y bc-., v(--ry

                            l@ut i,'- is one c@f Iclic,            1--hp-t are r
                       24                                                                  c,,p-@ (-, of

    Ace-Fedefal  Repoftets,  irc.
                       25   list. Until %,.,e           the                                      Nii.th fzic4-litic-,





                                                                                                          87




                                                                                            t
                       Ifor                                                  el          p

                       2


                       3


                                                              -C T


                       5           o,-i page-, 3 @,t t-_i)
                                                                               eys
                       6                                                         review conurittee and
                       7 the.,-% them Rn.G ijyid -'c-l-ion the,:@ C"IIP         1-Yould there be aiiy
                         in            th-                    lvjillo@y,@rtil           of tl-,a
                       8
                       9 Apsociz@.t-'-oii in                                        i-,.ake       cG'ml',',CTlt on
                       I 0t-I                             ci-r-     rE,.i-tc@loq,!iEts i:,e@c,- ii-i     .0-ical

                                                                                               p



                       12
                                                                                                          @14
                                  inl)t
                       3
                       1 47@md this             b-o by                  p7.@c-b@,,,blyc I don't kno7i,
                       15               DR.               S                                            4
                                                                      the  propo2als
                       1 6t r                                                      1.@ould       fit
                       17 intc--i-.@,)-                             iii                      eleti.--nt :Ls

                              14 C  C-
                       18                                                          o-,-.h,-r gro@ips         would
                        1 p
                       19 fc-cl th,,!y                   -'L-h@,      r-i.g"zt to              if  it  is
                       20 gi%re.-I to a            Pz!rt- O-.Lc      1,13dic@.1 Sociok--y group.
                                                                                                             t
                                                     j@  J(,ISDI@@T-
                                                                            @.7ould li)@c --Lo           -@ha
                       21
                       22 all the ch--ld2:er,. %@'ould ),)ct tl-i,@- sz).nc-,  just-, by
                       23 P@ut         is truly riot
                       4                 DR. TTIUR.17il@:   Thz;,.,
                       2                                                 .41ty arc, rxo,,L-.
   Ace-Fedeial Reportc@fs,  Inc.         SISTI-7P, lil"41%1                                    they are not.
                       25













                     2
                                                                                are DO comTr,@ -.3
                     3 about                                                          ifically.
                                                                    -0


                     4             DR@ 1,U@.YER:  All righ,,--.
                     5             DR.                                                 have
                     6 applicat4l,ons containing ,-;ome clen,,,       o@'         involvc,,,o' in
                     7  them, ci.c-ht of @qhicli       ii-i yo'O".-c      and ciie i,,h,-ch i.s
                     81
                       outside. There are t@-@to i-@yp--s o,@-,                          tl-ie blue,

                     9 tab ard E,.L'ter- t,Lc bli-ic
                     10            Befo@--c thc!-       tF-J:), trip% fi.:cst

                     11
                                      is


                                       f
                     12 -io r
                             c, ci

                     3             The          is a 6ono@-

                                                                                                y
                     141 to  procure c d v-@@-         vo fK,ci-a e,,t.      2                      z
                     15  from @@-cvcn        liospi-t&,3.s  ,@i v,h-',r,,th  isi @,t

                     16             to  the   p@og--a@m@

                                    The  appl4.c.@,ti-on
                     17
                     18                 l@.I.L@w Yor)r.                --irt z@In      tc)
                     19 a tr-'L-)--t2gion C"1-0                                          f c-,
                                                                   nagotialc-i.o-l b,@itw
                     20 entire areat but                                                 e r. k c
                     21 and. the staff said         inOividu,,).!        -chc-,y              -to gc-t

                     22
                     23             The   total!          reqi-lcrt,4Dd @,7aF, $27,060 for       first,
                     24 year.    Thi-, i%,oizld bc u@t-ad to
    I*                                                               . an O@,       I
   Ace-Fedetal Reportet,,, Inc.I
                     25 tc-ams.






                                                                                                I





                                                                                    ",Icre WC
                                  DR@ I,IPXER-.  LC,,t's

                                                                     pp
                   2                                                     j-
                              .,oing to go

                   3  at @,is poizil- in tii-r@-?  I,-,

                   4              DR.
                   5              DP,,:               right, I gu@.ss I need to be referred
                   6 to wh@-I.J-- I,,iiid of ral--criel and viherl-. is it in the iaz-@-cs thai-- I

                   7  m,--ty be mr-,J@irg            to.

                   8
                                  DR.                                  soi-Li@ coiiuncnts in  the
                   9  Nassau-Suffolk c,,n a N.;hii-,e ,@,hr@,ot, Ibelic@.vc-, not h@-,--i.lig a

                   10 foldc--.
                   11 I-                  -                                                         -I
                                  They a,le            I sc.@e.  It :Ls rio@l.it b-nh@.rd tl)e

                   121
                   13'1           Dr@.            Ccz7,1.d I
                   14 vi-here wa are?  Eass@-,u-St@,-r- -4'o 1 1, w h 4- t c-     31-,

                   15 Post-ilini SARP
                   16              DP,.            O@- the n--'.nl,, ),.-ogions   k-@"C@-,,icy
                   17 using the    geno-i-L)-              Dr.                   la-i-d d-c-,;,n,
                   18 eight, of         @.re  for   yonr                  Oiia of them is for

                   19 your   advice
                   20                                 is                             In o@.11in.,--
                   21  words   my                                    to tl-,c
                   22              Unfcrt,,lnztely, as I al,-!c) indicated a I-Lttl.-- cerlicir,
                   23  SODIC OJ'-- th-.,se                               dii@@i.i@ig tlii-s %.,Oak so
                   24  t@La't-- the supporting             is riot C-,).t

   Ace-FeOeral Repofteit,, Inc.
                   25  d(---,ircLblc@ either by my staff or by the reNr3.cw cc)t,,mitteL-.  I\Te










                                                                                                                                             th,
                                                ti I.

                                                                                                                                        T would
                                         2                                  she

                                                                                                                                        b@,  ti-,bc.:  ui-@d
                                         3by  th@-                              clf-!
                                                               tha,-  Ere  ee,,@iio"              tO                 to                          you  lia,@Fe

                                         5today.
                                         6                 This  p@,,,)--t  of  the  rc,,n,-,l                            proctircir@l-nt  progro@,,i
                                         7                              d  locv.1),y                                      by             IC,.,.G.     Th-- s-L-aff
                                         had  been  reviewc
                                         8revi@o@i  consumed  in  the                                      said  iE,,

                                         9of  -@Lis  part -,nf  the
                                         1 0                The second part of the                                                            home-
                                         't@--ainii,@,-j  p:co-@,r@ra,   t:L-Lc,@  rt;,-,,t,-,d                            s t o C          c., c,, p 5 0 v         i d c, c,
                                         1 2                                                              :E-c,
                                       .13 at                      of                                                                                riot-,   L7"-: r,.i

                                         to be a@,@z:,ne of thct fact i-h@,.t
                                         141
                                         15 training                                                                       y
                                         16 suc:cced:Ll@t  -,-i  do-rig  thic  c@-u4-cc@,  @qell,                      Thev v7erc rcq estilig
                                                                                                                                                   u
                                         17 $31,200        for th@i--@, c@,d                                                                                           he        i
                                         18                      and lot funded                                           @idv4.c,-e bz,.ck to th,- region

                                                              4
                                                                   ,nt@
                                         19 Zurich, in                   'lly, 1-1                      gi@N,exl to t-ll(-@                         nearly a
                                                                                       ad

                                         20 vcar bcfo,,-,e,         that in hc>i@,o
                                         21 indi..v4-ej,,,.. is w'L--,o              holy., to do -i.t @.iLd aCivic.,@ to thc@in z@s to how
                                         22 to go 3bo-Lit it, ai-id                they                      to have ignored this.
                                                              DP,. B'2c'SOII:                      C 1 i a        ri    r@ r- c@@ @-i e       n g t o b c t           I Iz  n
                                         2 3
                                         2 4about '&,ese iiidividi-,al3.y o-,;- are wo

     t-,ce-Fedr-,tat    Repottets,    Inc.
                                         25 flow?











                                                                                                                                                          p
                                                                                                                                                      C)
                                                                                           C)

                                                                                                                                        nine kidney
                                           2q u,-- n t i- a 1. ly i r., an E,                v               f z@
                                           3proposals that a-@e in                                                  cycl@
                                           4                  DR. BE.13SON.-               l,jill O,,c@y ))a                                                   of

                                           5                 revic-.w?
                                           6                   D R        H'-F N M PJ@l                                f o r b        n c,                     i,!p ahead
                                                                                                                                           tLrLg  t@l'i

                                                                                                                                                         fOr
                                           7of t@ir@qo is so vjlien yati 0,4 d                       gc,,@ to
                                           8  Yo" x,7o-Lld al2:ocdy be                               O:r wllz@.@

                                           I
                                           9on it.
                                           10                  DR.      DESSOli:            Thoy                     be a little b4@t YL-to.@-- e i n
                                                                                        Dr.                       bu-- I fi.nd i-.yczc-,If iio-'c
                                           12 2, i  r,- i I I C, t 0         t  y 0, 1)                                              it  i,.@                       c,@ut  o-i@
                                    .13                    i7it-.h i,,iat ouw-                      i-r i.@h,@,-cb i,-@ -1-@ loc3l,@
                                           14  areas in th-- cont@.e,-@t of c-@Fo.Ln -It,-4-nct that ic-. li@i@pen4-ng                                          h,@"  c-
                                                                                                                                                       But      1 jiist
                                                                Noiq, maybe th@t is iry cx,in
                                           151
                                           16  rrLcn-t'--4.o.-i that.       If this -'-Is Uic proc-@-iCu.re -c-r).at is going to be

                                           17
                                           181                  DR,                          14,iiz,,,Lc,.@vp-i.-  IFou  all  %,;zuii;.            I  hand  no

                                           19 vested intereit.
                                           20                   DR. DESSON:                   I v@,ould rather loo3,, v.41-
                                           21 in                   so @,7e @,iotil,d                     what is
                                           22                   'DR. THAYER:   Yes, Mac.
                                           23                    DR.    SCHK.IIDT:                            I                                         that-. c@,.rtraL@ed
                                           24                                 does.           I rup
                                           is   as   castva'k-cd                                         poi--t Jei-ry and

      A,.e  -  FedL@tat  Repor  tefs,   Inc.
                                           25 be I.oo),.cd at as              we look -@t the regions,





                                                                                                                  92


                                          DI,.   I-IAYEl@;    O.Y,.    Is          them. c-             of   thc-

                          2


                          3
                          4the qcic-sl-iozi           is iAc- thz,,t       a.2:c-i  doiiicj  at  thi-F,  point   in

                          5timo
                          6               DR.     H I l@l I    B-cfo--e I                    the cl-iai--

                          7
                          8                --   riiy   staff   assures   ma   these    items    I    distr4-b-Lited
                          9   during the bre@t", @qere                            4,-o the
                          10   0--i,-- of 1-@hzri is a           dc-atcd rc--):)iuary 25,  1972,  and is the
                          11  -guiec@'d@-irs-s  fo2: the-, E,'L,,IS               that Dr.  Scher,]-i@ ol-. Dr.

                          1 2


                          14 -Iat@.d ilarch 13,  one dated March Ilz,,  and one dated                           7,

                            that N,7c,3:e Sent-. out coiic--;,rniiig the
                          15i
                          1 6devel.opmec!nt                                          just Tuc!sday
                          1 7Th;,,.t  -7,-s @.iliy   of yoLi p,@c@b.@ly did not ro.(.-.cjve it.               1,@a


                          19               DR.  l@'IYER:     I i-ioul.d bc! dcligh@@L-c-d -co tall-. to
                          20 your s-@aff is who has (jo-i--

                          21
                          22               -DR.                Beli,eve ipe,  as confusing as tliii-igs
                          23 have been,  I cm..,,.not be Certain.             That  is  Njhy  I  gave  t-.1-ieyri

                            to you.
                          24
     Ace-Federa[Reportr-is,lrlc.           DR.   P70-IL.-   Wc)..I, i-7c,- on the                                   if
                          25










                               1         the
                                                                        riCt              or

                               2                   A@iici all N.,- cEtn plead is it-1hi,-L i-l- has
                               3            Bv-t if you                     rccz@i,v@-d  it,  it:  is  really

                               4inc>-cusable.        So   @qe    do
                               5              DR.  Mi-@YER:       04k-her ite-iri--f  I.Ic!rbe            rc@ed  t-o be
                               6           ,I--o the:                     attenl"-ioii?
                               7              DR.  P@,!L:       I  thinlz the ci-ily one front                         Dr.
                               8i@ia-guj.4-es I-..Iantc.,d are to   rcnt.i.oii   %ihich   is   a    -@-e@-y
                               9is &.n                               has            rc@.ude               @-he  tiir,-n   -,L-hat
                               lo YOU  lasL. meet-. Lrd   this                     7,@nd          -icj -Lh@,t.         Jr;dv    S
                               11 -is t'ie Dapi@ty D,.:rcct.(Nr of tho                                             s   wo       :-i
                                                                                D-4.vi@-Lon of C)r--arat-'o,.
                               12                                                         tl-ie           01'         of-

                                                          bn-@n                              yoll,,

                               14 to m@,ntion thi-s pleasant duty.
                               15               So lir-Ae  Sijsb,--,e           c,@,hE-.rtgcd liats z!.ii(I i-s
                               as D@-puty       i-xi IL-IILE              of                     tlio@Fe. pasha.
                               16
                               171                                     Ich,-in
                               18@              DR.                    Is @,hc to bc-                              or
                               19               DR.  P2,@'iL:      I   aIrL,.oFt              no-r- -',-o @.sk ha-@,
                               20               D),@.  IV@Y-rR:    I   no,%--d to ha-\,c. bc-,fo,,.--@
                               21 &n OPPOrti,,rii--"Y to                  on t-.t@@e order in wb.-i.ch              ta@.p-
                               22  bec@-ase of people's prc2@,nca,  rbsf-,nce., c@,lt--c.                 T,,qo
                                          iarc-, of  relz,@4--e,                         in           if,; @,m
                               2 3


                                      E71@,.q c
     0                         24  Etlli   c,  and  tl,  at   is                             zind O').,@,io, both  SI-4ste,):
     Ace-Fc-defal Reportets, Inc.
                               25  and my--elf.      I am not go4-ng to b,-- cbl.e to be pi-@cr@crit tcir,@                   r@OT.-


 w@f @  5 c7ri



















       de                                                 06




                                                                                                    9 4





                                                           am


                                                                                                      w
                      2iii).vr-- thc""             of tai
                                                                                             the
                      3                                   y
                      4 s?-ateicent.    it ought to be, but isn' t                  -'.LY linl@ed '@o
                      5                 io.   But   ?-Ila d4r@cus@ion ought to go on bacli@ to bi7Lc"r,.
                       No-tiloast ol,-

                      6   -r-hi.r,.k, on those tl.?O.
                      7              Are th@c-,re, cithor speci,-r-4c p-robic@ms?

                      8              Johr, l@rale@-iski will be in
                      9 z@nd Dr.               ought to be ii,4.                       to pick
                      10              Is         crtiy@onc- els(@ N,?i.t-h

                      11             Phi I?

                      1 2             DP,,                             by

                                      DR.
                      14  conflict         schr@eijlii-Lg              th-@n        I          p@@-c,,pose
                      15  to    N,7oiild bi to start. o-Lit          the                          of
                      16              a,  i-, s been         vis4-t,@-r-1, Nth.@cli   I,";hit,-- doos li,-tvc-,,

                                             for.
                      17  r c-, s,@ o n:-,

                      1 8             Phil., it is al). yours.
                                      DR. 1,@,IITE:   One is suripOE-.ed neve-- to P",7e@@ace con@i@,.a
                      1 9
                      2 0 @,;-'@th an r,.I?ol.o@fy so I sliill not, bti-L I would lil,le, to
                      21  something to YOL', e"s my presentetioii ma@,, be lcss than sparlzl@@ng,
                      22                to an experionc,,-- @,.,-hich was sorr,,--@qhat di,,3t):cE.,.,:;j.ng
                      23  %.;hic.1 hz,.s Ic-@ft- ir@,                                        I t is

                      24  coivi-ri,,,rit on o,,,@  L"l
                                           r hecl I    came sysl-c-i,.i        perhaps IV@R,PS ro.- y

   Ace-Fedefal Reportefs,  Inc.
                      25  eventually in'Llu--,-ice.









                                                                                    d  in


                                2                              Thir,  iG  @N
                                                                                                                 i,n D,@t-e@04"-f


                                3@ih\r  T    WC.
                                                      10
                                4                   Ho iqz@,s                tc)  a  local h(.)s@)ital  at              4:   30    in    the

                                5 af tor                      _o  c
                                             ci o:,. .  A.,,- I                                                    f t'
                                                                      I clc>c,,- or @,hort'@',,y tk,OreZ, c'                          as
                                6 finally  put in             bed.       lie,  in  the mean,tilna  occupic(ft  a  cor@-""-(3or
                                7 along                a               Of othc,.@ c@lderly                                        were  also

                                                                                                               thc-r.
                                8 r.,Y,3paren-@ly                            Of oiie  sort or ano

                                                                                                                                ow of the
                                                                                                ap
                                                                                                  ., p)-,,
                                9                    im d  I                                                  iFte in       vi

                                1 0
                                        r cj c- r, C. ysy@--cm
                                11                                             of h@ r.,  expo-rio,-,ices  thc@@@-C,  he wz,@-  -.@)!-on
                                12      tc-,,                                                  t I  s           s  e. I,.  Z? 1   o  t I
                                13, c-t;                                    h@ip  or                                                e        a-!-
                                  lie  had  an  v@rge  %Aii-ch                     ps  relal-@es  to  tl-                    'L  prob.1 c     s
                                14                                                                                 e

                                15 have  been  tal}zing

                                16                   To ny                                     i-,,as r.,o


                                17   vic@.@'lit"
                                                .7 ,  r--iid no one                            to   ht-@@7e    t-.he    vutl-,--r4-ty    to
                                18@ i ri el @L c a .1@- Lt.    Ol-).e  C-OLl)-d  bo  r,,.,--ocu-rc@c3.      So     I           .town  to  che

                                19                    )-,-oom                       C-, )Dci.lig
                                20           tlic-y @,jo@ild usually  he  in  a  closet and prl-,cu,-cd one  n-nd
                                21 to@-  it  U',f-).                      V:Z).S  a  littlc-@  agh@@-tc;t  that
                                22 a white c-actt i@7,-ts cE,.rryii-Ig a u,@ii-iz,,l arc,,and.
                                                      V?hil,e  t@,,p  in                  du-i.ng i,@h.;..ch                      s a,%,i  ve
                                2 3
                                2 4  C-' w T),-Or)le,  o.,ie-of  tl,&--                   c@l.c4c.-,.:Iy  gcntler.,,-         there  had.  a

     Ace-Fedeial Repofteis,  Inc.
                                2 5 cz,.):diac  arrest.            And  sudden'% ,  all  Of  the  dOCt.01,75  vihich  %..,e@-C





                                                                                                           9 6




                                                              'CID
                         2                       thc!                                  got his hez,,rt-.
                         g    CT a.(Ye-int              x@jl@icl-i Play !7,tooci aroiird  ancl  d-,.scis@-c-d
                         3


                         4                  fc,;n
                         5            Thc-          of          @!hol,c                 is that i-t was
                         6my         -@oersonal                                as                       Put I
                         7stood   IL-Ili-c@re   -Lor   a).l    tliosc-    hours with my                I d   d
                         81 not iC,.@nti.fy n-@zyt@c@-If t-&-s a                ttm lioi)@f',Il  tll&,t@  it
                         9                                               if I 1-ia(l.
                         10            Finally,  an                    sr,.rg;aon di..eL E:L-@-ive o@-,'i  the
                         11 C-2,-Ic, !-I--  is       a             to                     exactly

                         de C 4 j@@ 0 -
                         12                     I-T@c,  di-d                   I.I@  -L-(:)
                         13                                                           4,Lii Flo            to
                         14 1            @.e discuss@,r@ii,           them proc,--sa,        go,".ng   to    h-a
                         15             The r,,oint or                      I  guess,  i.3          I    hac,.e to
                         16 sc@e If--Irg:a con'--rLclt---- be@i7,@4-tg   cr                 core     c-,ystc@-@,s
                         17 %@@h-&ch     cr-@ha-@ize      the                                         cn ',.he
                         18 h u r@ i v,,i- r, i r-,Tltg @h,@+- bc-  cc,,,        in oi:,r
                         19                     O,,-@r:7,. But      h,@E;
                         20a                                        tci
                         211wcy.   I'.rd  I 1-izi@rcA,ilt be@7,,i-L to cost  it         o,-' r,,tu           d
                         22         proba-@).v write                          tO the hosp4-tal
                         23 and nov<,,r )-)e  z,,ID).e  to     vt-ilr     -@r, Datroit  again.
                         24             P-n cl I  zLtr, not pickiriclf or, D--t-roit,  Jcle..

    A   Fldeial  F@epoftefs,   Inc.
                         25





                                                                                                                                                                     9 7



                                                             P"2                                                                  id                  tile.


                                 2                                                               And D@-                                            I  -0     F@S


                                 3     vs             1,,,u
                                                                       ar,.d                              Ai,d I

                                 4     isback  the@e  today  looJ,,4)-ng  @,t  t,@he3@-y:   Icid-gi,,,,y

                                 5                           The@e has been a tu2,-novc-,:c ol'-- coox:-din;i"k-lor!f-- i@n tll4@-s

                                 6     region (jv,--- the                                  I thii-Ak thi-c,-!  is, wh@,'---,  the fourth

                                 7                           cool,,diya-Lor.     Aiid.     the                               o,-@ic-           been on boacd

                                 8     s'oiaothing @--out a year--.

                                 9                           in  -cJ.-Lo  pz,@",t,   ti-ko.                              of tlio. Orc-gcn P,,Bg"'cna.1

                               10                                        fare la--,-gcly                                            ori(@l-ited.            Th@-I-,,' h@-,,d



                               12    1                             T)i,@y had. co@coi city cE,,-i:e                               ',-(j               @i,,-id

                                                                                               @@CtiV4.1,ie,               TI.) ey    11 Ve
                                                                                                                                                  ---I.  ul
                               13'1

                               14  of the near roission of the Pegion@,l

                               15    and     have     adopted     objectives     and                                                  ccein c,@nsol'i@.nt wi'L-,h

                               16                   w ich have been sucFgested  ,'rose Washing4@-on.

                               17                            They hp,-ve@

                               18      as tlioy cz@ll it,  in th-i's pl@ini-iig -for tla.@ iiox-L                                                         yca@rs

                               1 9     And i-'c.                     to Lis tlip-t th,@y,                                                             and

                               20                                    Their  staff  is

                               21      %,7ho     is     the      new      coorciii-iz,,toi.-      is      a                       capable  Y-.E.-n  \@l,.o  1-ias

                               22                                                                                                 d ob-
                                       sp,lirred  them  on  to  changing                                         gor.Is       z@..n         iecti-\;-P-s  end

                               23      to  participzt@-ng  in  the  develoi3i-iic!nt  of                                                              z,,n@d
                                                                                                                                                                                  i
                               24      objectivoc,,                                                                                                                               I
    ',,c,    deal Reporteis, [,,ic.  1
                               251                           They  are,   as  you  can  imagine,   related  to
                                     I





                                                                                                                                                                   9 a





                                   2                                                                                              wllicli are


                                   3   Yihich                                       a   e-       y s

                                                                                                                                             N-"itli tl,71C
                                   4                        They  fell%-,  that                           ware  'r,
                                   5                                              and  goals  and  @,7c@.ro.  rclcv,%n.'-  to                                  needs

                                   6   in  Oregon.
                                   7                        They  had  d4-fferen-'c-                                   by                  these  q-cic.:Ls

                                   8    i.;ere  to  be  achievcid,                    Th@-@y  hid.                              st.@.3.,-,Cts  O"-

                                   9     and                ;,,-,Iiich                     to  tl-it@                       on

                                   10                       We  :Cc-,It  in  revic%.,,ing  tl,.@-s                                                 th@ir



                                   12                                             of                  goals


                                   13

                                   14  -Icliai--               heal.-Lh                                                                            scme
                                   15  proce2s                              in  the                                                      c,,.roalr,  arid
                                   16  objec4L-iv(--.s,                                                             L@ljlzoly  that                             Is
                                   17  p r 0 b i - c- r @', G  're 1r. 0.       I v  cl     f   c,.,  n. t  f      i r,  t h a r,    o f t h             s I-- o f    4--l p-     i
                                   18i country.                                             it                                                                f-@'C)I:t  I-,a

                                                                                                                                                                    -d
                                   191 undartai@c-ii  to  st:c@,iiclchei@  tlIC4-  d@,@@i  b-se  so                                                i-@l-iey
                                   20                                                         O'-   10"                   rc@w        zictiv-i,,--ies         v@k-,Ijld have

                                   21  a- n                  on  the  problems  in  oregon@
                                   22                        In  the                   as         I         men,,--ioncd,         trey         hav-e         emphasized
                                   23  edticatiortal                                                                         t-%ey                 also           vci-y

                                   24  activ@         s    a f f  p,@ r- o'k e ,   a, n (I          y  @,7 c@ rc,   oiit                        uLD

    @ce- d,,al Reporters, Inc.
                                   25  d-vvloping  relationships,   Died  a  1-i,.cji,,.I.y                                  qualified  and




                                                                                                   99





                               hi-

                                                                                          -c,-Iat,- to
                       2                               be z,@
                       3              -y                      01@""P        i@Lre rII02:e Coi"-Iplc
                                                                                  so that the
                       4  C"z.-cs flood and accepted by tho co

                                                                                           otkn b-cst
                                           havc @-n                        to lioi,7 th,@@,,


                       6usc the
                                                                                          n
                                                                              TI-iiS  iS  i   ie

                                                                                                 and
                       7
                                                      -s ill thcrind of D

                                                             r:,-tiu,f ,,,itli thin in min@d.
                       8illa has plans to incr,@ctse the
                       9             so@   of the               Irli@,t have       und@,-;-t  en in the
                       10     hav@-- bez:rt pliic@c-d       They h@i-N7e attei@intc@d to devclcp
                                                                                                o,'. the
                       11        funding   for theac,, and               in  take   acCCII"

                                                                                          by-
                       12
                                               ct.,ea;.


                                                              -id (-)f
                       3'                 t
                                     In som-3                 at                 of the p-ojCC4,s
                       14
                       1 5have beon tLkeii o,.re).- by o@-hcAr                                  of -1-h-c;,
                       161                            @-or             by                        C) r
                       1 71              by soma of tl-ic institut-4-ons b@nefit4-nizi from tho
                       18               activities.       Not @,11, of '@heir

                       19              ho,,,.-c!ver.
                       201           You n4Lght noi:c@ in the priiil-@-outs on tire
                       21 ass,-,,--,sirrent     that there is some                 of
                       22 funeii@-ig I-)y      sourcf@,-o.  in             to                said 100
                         per(,,@,nt of the pro-;-c-l-s %@;ere          by                  you Still
                       23
                         note that th(@re is a                                     O.,@ogon.
                       24

         deral Repoitct,, Inc.
                       25             We looked at the m4l-nor4yty inter(z:s@k--.     it .4@s intaresti-r





                                                                                                        100




                                                there area
                         to note    ho-,,,,cvc@r

                      2                 o): at IC,   s           @ho  rc-@  iy-,.

                      3  rL u,- Il
                               r vc@-"y            f,o it h@-I

                      4  equal or pz-oDer                         on

                      5  in the Orcigon

                         x.ias r c c o i i dd
                      6                       than thciy unda,,--take

                      7  f o                       f.'Y--oia the
                      8       bl@acl-,s, z!n(3 them                            Fee i--F

                      9  e,,it4-c@:a                      oil         b

                      10              Wo                     by Dr.                        an
                      11                                            -co              his, :-,taff.    liF c--

                      12
                                                                       0 Yi .              o, c,,p i n c,@, i

                      '13 i c@ "-D                                     Ftz,.f -F.

                      14 of                   I,,Ie 4cl"iinlll also that he had

                      15

                      16 ano. thc@t Ic.Iiiay --IioulO, be
                      17              He had                  clone --elz,,,lt4-onsh4-p:7,      the O-.-@ecjcn
                      18                             &.,nd he           to bc                iiot
                      19  has o-,-,,n r,-talf and                                  bL@-@- 1.)y o@licr     -:arm
                      20                       o):gl-@i-ii,-@.cll,--ionE@- i-n the Di@_,
                      21 need,-! help, hc,@e@,7c!r.                   of oi:,r
                      22 hc! seek a                                             t-o  C).SL@i Iii,ro.
                      23               The core st--aj@-f is          up of
                      24 reviewed                                               acted          to

          fal Rcpotters,  Inc.
                      251 tl-,c--Lr bacl:a,@-ound wind            for us.     It secmc; that th,@,y @@c-!re




                                                                             L UL




                                                        Thev 1, @-v,@ d@,

                2                                                 of -"--ho
                3 t-                                       page         of ):)udge-L
                4                                       cuts    br@dg,--t C,.4Tnr@
                                                                             cl-bou--


                                                                         but ratj,.
                  ,IC --@t)             r)       or program

                0 t o c ubacl-. on core Supper,,.-.
                7           So    v.,ovild rc-,cc@,,.Trc-nd to.o:cc--goii if tl-ie f@n-ting
                8 is          by this bojy aiid Coiinc4-l- that stews be undertaken
                9 to strengthen        core, ric>t    E,- que,.Iil&@.  si-,and,@oin,,-- so ra@ic-
                                                              y


                1 0as fro7i a
                11          The           ...Ca%ri5o@-y bol@,".y was roprcse,.itad in  fo---ca.
                1 2          a         o@,

                           h c u @iL
                1 3'  a,,. d                 t@,@,C) c@@,y@, cf @-he v@@  O.L .,-I
                                                                      j4
                14         o        L,,.it ak"   by tlir-,ir        in   -,t 4ng
                          c


                15 1 sUT13 Po r "r-
                1 6          Ile acc; told    tlic-           at thei." meetings is-
                17   good.   Tli,-y   have indeed as yoti will note in the s4@to vis4-IL-.
                18  rcPO2:t                         @-,,ho attciid@.nce vjas not good

                19  and replacer thc;;m.
                                h  d %74-dc-@lic-@ tliE,.t     of th,-- regloii,-zl
                20,
                21 Pdiisory Bo@i@:d           on                   M-L         role
                22 1in the           of               p@-ojcc-'W--s.
                23           1,Je did no-r-e tliall-- tl,-.ero- was a dccrtli of allied
                   I.) -, 0 po n. thi.s corcni.ttcct and
                24

        tal Rep6rtc-is, lnc.
                25  that.








                                                                                                C>f
                                             Thez,e  arO nO PrOhl
                                                                              C)f                                  dic,

                                                                                                                C,
                                                                                                      f P
                               is  tlivt
                           3
                                                                                                                and I
                           4   very bec,-inrii,.ig,  acl--'-r-9 cni..y      Ec--, t h c,.  fC,
                               Dr.  Pahl,co,-@qpl@eic4-lY cc)nfoc-z-.lirlcy     to t,"O  c
                                                                                                              @,7hich ycii
                           5
                           6   read to us earlier about the relations,ii,ps beti@.-ean  a rea-4,onal
                                                               i
                           7   &dvisot@,  group and g@ante,@,  ox,ganiz                   0 n
                                              We did n,-tc.@            pnoblem in  that the                         scelc- Of
                           8
                           91  'clie University of Oregon  Sc,-hool of I,,'cdic-ine                                   D,-c .
                                         mid@ has       h a d s    c    d                     recruiting certain
                           10     n s cla
                               I,.iiids   of   pcop'ke    to    his    ctaf,'              he  is not
                               Thc-,v                  -ng                                                      @.b      t o tli
                           12
                               c,z, dtlic-v   ma%,   clicrjzta   to   go    to      routa o-4' oil
                           13'
                           14  corporation.           llov7aver,  the so--v-4- c --s p@oviC-,,cd by  i,-Iie
                               have value,        end            do         -v,,@,nt to                   thiL-,
                           15


                           16
                                                             enO, th--@.  troy (5,,@
                                                ee         -aq                            givc.@   ll,E,  @,c-rtoos
                           17.
                               and lco'i,:  a.,L:               alt@-raativos                   to
                           18
                                               Du&-ing   th-3   site   visit,    @..e    hz-id    a            of
                           19
                               by o4@@--r people  frw,,i cth,@@,r                                                       a
                           20@
                               fropi. the CIIP B agenc4-ie@,,           voluntcer            healt@
                           21
                           22  ilodc!l C3.t@-cs p,-,or)le,  tlip-       president of the  State
                           23                       and so on.          It          apy,,a.,:c-n-li--  tl-lp@.t
                           24                                                   )jot-h by  -'@-h,--        in    I,, o E,

    Ace    deial Reportcts, Inc.
                           251 activities    and    by    tlieiti     i.n              activ4-tics.





                                                                                                                                          -LO3




                                                                                                                                 are  i,@rid


                              2                           @@2orlci.ng  c!oeely                               develop      a       pep-r

                              3                                         o-ther
                              4  pe:ct@..n,-@nt                              of                 To            extent,  throug'ki  --@he
                              5  efforts  of                              li-L,ld               b@.an    (fic@@,@olopad    b-,.r    the
                              6  0--eaon  kieci-i.ca"-  Pssoci-alc:--',.on  a                                  that            marlibc@rs
                              7           certv,-j-ii li,.,urs  of                            c  odL,               )-n  o@--der to  be

                              8                  foy--                      in  tlia4L-1  body.        ATz@d     indeed     i     haNre

                              9                    'che el-,act@-                                                 11

                              10 of   that  society had b,--@czn  dropperl

                              11          f,--iij.(,id  to   m@-et-.   thc,,,@e

                                                                                                                                   ti
                              121                  I'@- was
                                                                                                              c;@@-,c4,-i           and

                              14 assistance,  al-@iouc7h Pr,---r'i-taps  tl-io2.-e N@,@as  z!, n;,r@,ed  fo.-  @-ic-m  -"--o
                              15 clearly  uiderst   d %,;hzt@@.-L-.  OR'.LP                  ;,,-Il               I,,Ild
                              16 the.4---  @@-acre  should b-@                                             of  OR!t,:@P's  ):CIO  i--o  t-lic        i

                              17 O',h--r-  health  Egc.,ncics  i,n  tli,--
                              18                   There  are                                  ho@eltli  pl&i-anii-ig                       in
                              Ig 0 r c,-, r-, n  There  is  a                                                           No@-  sell  o'L  the

                              20 B    c.@cncic-s     are     1,LU-ICI-io@--141,
                                                                              ,g                                          iz;  a  clos-c-
                                                             .L     4-..   I,-                     1
                              21 relatio,,-i@,h-',-p between i.;h@@i-- do--s  e>,js-c  i,.n  tl,.o.  CHP  and  @n,,i
                              22 They  abide by  the                                         i--c,-quire  jo.-'4rit                ard

                              23 co-.r,,monl--     @.,,here      6@.pplictb).e.
                              24                                                                                                       a

    A,, @dral f@eportcfs,  Inc'
                              25   relative  lac,',.  of hard din,-La in  tori-ris  of hc,,.Ith nce-,,Is.                                  they











                                                      Th@.-,r

                            2noc:Cs asses5rio@it unit z;,P,     )?z4L-t of 'Ll@-icir ne@-I
                            3                       his                     in.                   wi,@"I the
                            structure.       7-,.n d t
                            4                       uni4l-- iri the CHP agencies                    th,@y exisl-- ir.
                            5th--               'l)-@ undox.-tc,!,,-i,ng       studies of what
                            6in   0--@egon   to   develop   a    g,@,caity           care                not jus-t
                            7only from the standpol-Ini-, of                                               a lac'j,, o@
                            8             bulc pr--s--ha@s more fr@,  the standpoint oAr., the provider
                            9dc,'Lirtj,.,Akg    nr-,-@ds to b,--. done,  N,7h@-t procc-c@ sho-v,"Ld bc-, uricer-
                            10 tzJ-.cr,.,  ico rce-L-. the needs.      This needs
                            11 'N.7ill                                                  of     they tell IT.0,

                                                                                            C;"-; CT
                            12                 c@.,:otips            the! S@-z--
                            17                                   &


                                                           rL,
                          .13 ij Y            12 o:c 14.                       rf a
                            14           They   will be d;-@,octc-@,d by                                It @7ill be
                            151                     I,--'L-v to detc--ii4-n   z.,nd dcfino i,.,Iiat is
                            in a p@--r                            h                        'L'"- i-@h-cit th
                            16@                     arc-a of                       1-7o fe.                S 1,7 a S

                            17          CT,,       cf d-@IL-@.cL---.ct.'I.
                                           Ile h@,.%;,e lil--'L-le or iio-q,,,@stioxi @,bout the                     r-.f
                            18,
                            I                                                                                                1
                            19Im a n2 m.-- n If-- o f th 4- r, r eC i-. T 1-i -c E,@ Ic a f f w a, s @T o o cl,I  :I t i 0
                            20 -thc fisco.1 agei,xL-. was goc)(ft,                   ,-io                      the@-.te flat
                            21 =Iy r,,roblcri xi--th tl-i@. @@7@,y  t-l-ic:y                    f-Lii-,.ds o2- }:cpt a
                            22         on 'tihat', x,,TE3.s cjoi.x,,q on ,L,n     regioi-i,
                            23                                         to         @,7EIs th--  c v a.1, u ao n    o c,,
                            2 4T cri2,--%cs thez-o. hcl-%Fe bann sortie prol)lc-ms hc@-re      in the r@r@rise

   Ace-Fedetal Repoiteis, Inc'
                            25 %@jit@t budgcll-- restrictions,  Dr.  Y@@gi was 1)u;-,          on











                           Ilan


                          fU,l
                        2

                        3                                               they           to I-C)OIZ at
                                        p.nd w@
                        4  other kind of evaluation,              Thj-y hE,,Vc;,                    at
                                                                                to              they have

                        6 achieved             IFOels or objc--,@t4                                      n @@ - 0
                                                                       ves.     @ld I guess as so'@ -,-
                        71 has said, tl-l.ev have ap- H & H @-         pe of -a%riluai-iori procosc@',;r a
                                                                    @-Y
                        8 he@,d count and                        iridc-x sort o'L evaluation.
                        9               Dr. Yiqi, hot-,cver, s-earr-.Pd a                    @o@--t of rw ,,-son,
                        10       orgeri@---ed,  d,-oci-pliiicd r,.i@i,  and e.-a are hopo-i-cul that
                                                       cor@-te f--ro-i his      I.-time                   I)y t@--he

                        12                                      o @y  T,.,.

                        1 3                                                          to
                                                                                                  Y. n t o f.-


                        14                          cf goal.s .-@-r2.d objectives.
                        15                        -tlc, e.,ct4.oi-i pjlz7.n, I' need r,,ol-- go into a
                        1 6eaal roore b@Icause                  I hl-4,,lo c-o-@ci@-cd it to copie exte@,.t in

                        17 Y,@-y p-r,,vc,,os                They area

                        18
                        19         go&-).r, ziid                                                                 o-,ne
                        2 0o. LI  c r, -, c-; @I z-: 'Rhe.-N? @irct  T ti@ii,lkl,  actio-,,,&
                        21                                 one                                     add
                        22 that relc-_Ites to fL@r-diiig.        You r,,ay notc,            in their

                        23 -,,Iioy have a-l@cd fo:c                                          .&  1.    -
                                                                              He         a 1, t- @- le b 4 -L- o f
                        24@ cli f -L (,@,a 1 lc-,,, gr    w ii--Ii tli  bL, c@,v-z: c  wac-n       le@ ar ii-i i,,iy
   Ace -Fedc-tat R(@portr,,is,  Inc.
                        2 5raised at -Lh,.e on@,--t, cf         dif j@l-c@rc.,nce b,@@L,.@icen grci@@q,-_h     a)@id






                                                                                                             .1 0




                                                                                                            b 1

                        2 1       thi.-@,  buc                                                      c@.nd

                                                                             of   th@-..;-3        fII2.ly
                        4               ard.,                                                o:E -L-ho. --pec-&fic

                        5budg,?ta):y nc,-@ds Vehicle N,,,oulCk )Dc.@
                        C)                                                                      growth finds.

                        7 to
                                                                                    -cct                the


                                                                                    rrvet


                        9 cariiot                               et
                        10               Tl,.ey                      gro@@th f,@,ids             @,clat-C to
                        ii                                                                     in r-,irzil  @--d
                                       c@ to                                         cli

                        12 r i@11.0
                                               f


                        1 a@ez),s,  @in(a@ z.
                        I

                        14 7 i t h                                             tc@r&-ibly
                        15                s--i-isc            'L-h@m e,          cl@.C-.@ck. P-u@@- a:F-.t-or

                          Cl -' E7 CU_ S 4 1-1-f
                                                                         d@@,cl c,@e:rLt to               th,   -.
                        16                 :h                                                                  @ro
                        17               r,,:s 44--o                              that thc@,,-r        no'-- -'(,hc-
                        1 8.                                                        thcni           V;-ew
                        19                              -@n            uL-        OA' clll il-,ft7-:1 L.

                        20
                        21 inaccessible a.)--cas to                          back z,,.nd                 to
                        22                                                             to          l@nowl.c-dc@--abl,--

                        23     resourc3ful
                        24                It inay 'iD-, a                     N,7e lic,,.v

   Ace-Fc,ciefal f',eportets, Inc
                        2 5' @irc-as for: ge'(-t3.@-ig                                            I)".r a





                                                                                                                                                               1 0,7







                                    2   a t i e- ri t        '--tie
                                    3                      The-                                                                                      4,-lc,,   bi@
                                    4   i,-i--bulou,-,  I                    irL  the  sc-r,@r@a  that    ,"C-,@y WC-,ZE P;.-,--sumi-rlg
                                    5   i t- h  a p p,-           a t c-  f    r;  n c i a 1  i      C. c-!.rr    i            t h c @,  c o u 1 d e s             1  s h
                                    6   f@,rrLily p.-L,,cti-ce  el.in-ics  irL                           s                doaL-07.,@ li--,d not
                                    7   previously  chosen  to                                                                                   that-.

                                    8   r,,ocbuclir,                      h@,d.
                                    9   They  felt  t@.hat  r@-rhaps  this                                  mo,-re     i-,.hEii             Avoiding           a
                                        ,bu4-ldin@-j  J'o%-                         to                        i.n;     tlivt  th,"y                       CYOIIIC'   uo
                                    10
                                    11            en cf@-or,t  tco  d-v@-lo-,,3                             to                    in  i;I.C!Cc
                                    12  A, n ri  i, f  t:- i       s  1-@, o;@@                               s  %@ o      12@         II    c@ 'o @  ;I p      c- I   i.;-, c@
                                    1 3                     Yo,,x                                                                                                     .1 1
                                    14  E d,,7@,-- @z o i i      :Ce@@7                  c?.goe         d  T  cFnlt                              tlic.,
                                    15                                                                      oi-'   @,;Ii%y    raoopl-e    1-0     i@-t     prac@-@'.
                                    16  in  rural  areas.                   Px.,.d it                                                  -Lo            -.cE,,ct  !--,h-@t
                                        dc,-@tors  feel                           when  lc-b(-,,@  care by                                              thz:.@--
                                    17                                         $                    -                                                                    -       I
                                        r3o   nc--d                        'find                                                             @.,bout-.  tha,,-i.
                                    18
                                        Piid  5-f              O@--cgon                                                              c@'M  ii-ids-ctcl
                                    191
                                    20  t-c-,ar.,.s  in  ).-niL-"Otc                      .4Lt               be  a
                                                             So     it      i@-;                                  to                              of acAL,.-;.v4.tic-s
                                    21
                                    22    that  tlic-,,  leave  asked  for                                   funds,
                                    23                              f@o-el  that  the  C).-.-,-c.@gon                                Mcd,!.c@.1 ProCjr4F.,,,@il is
                                                           lqf:: fc-,@el t--hz,@t wi.1711                     of i--Iicse Projec@l-ed
                                    24  strol-ig-
     Ace-Fed(@t,il f@epoltels,  Ific.   thc-.         davel-opntent-.         of          yit-@ed@,                            unii7,  P-@,id  the  hce,.Ith
                                    251













                                                                 c C)';  C.-@,
                                   II-! @i t
                   r C;



                                                              A
                                            th C, i
                 2


                 3

                 4                              ci.1, the teci),,! v7i@.s  that

                                                       ,O.S @la-4
                                                                      .T.,.. at
                 5 this wais a good i-eg;-on card that
                 6   (4 n cj n 4 n cy r e c,, -, 0 -, it 3@ C, nt-sI g t 0rc@D.Cli ov,,t
                 7 in',L--o tho total'-ilt-- of -Ich@, ii  of ti-ie     thclt about
                                   y


                 8
                   70 pe@-c--nt of 'clie potv,,Iat
                 9      @,,,ould lil-,o Dr. Tliiiy@,inaii to so,4@ti@- Et th4-s
                 10                  to do &@o       @f.,e tEill-,  the fui-xCi-ng.


                 11          DII. I,',]iYFR:


                 12
                             DR. 'O U F,@'                          .1

                 13 C,.V--IVA,
                 14 cc,,rce:cnr, v-7aG coca.    i.s too SYCIrAll -L-0 do P,7,rticu).@A-I,,,
                 15 i-jith the new th@u--t jai) that they are trying to do.
                 161         W e w e,,. e ci I I i m p r c s c: cl h o r. p n,:@ w n, Et I t- h z,, I-- -'C, h c-: y
                 17@ had, F4dd--d     P---nd I.loi-i much time hc- @-s  on
                 18 ).-cad and br--,Ii-i(-ii-,.@,
                 19                                 poii-it    h-, m@3.Cie and t-hat-is

                 20ii--hz@t               is so st--ong      if he     a coco-n@:irv
                 211to-..orroiq, @iey might be in troublt@ real'I.y @--catise there is
                 22 no d--pt:h. So.tliat all of us brough-L. ov,cr to h,-m Ft@Tai.n the
                 23 buf;ii-icss of nec-,d.Liig a deputy      to       I'P    of

                 24 4c!iese i-Jii-i-Lgs.

  @@ce-Fedei,-if Repoiters, liic.
                                          only otll(.N
                                                  .r t@.:o po4ntS  I  ,@'Tot,
                 25          I think                                  Id iLn.Or@rline





                                                                                                                                                         cl, 9




                                                                                     t I            y             y  d
                                       a U



                                3            h@;.d                                                 ef  o,@l,,.                   t-hca  f a@--  'chat
                                4   once  of  IL--IH  i-r  core  st,-,ff                                                               this
                                5   rc-a@ponsi).)i,  I   i   t@y.    I  believe                    our                    vicit.         ve-np
                                6   ii---oful  -c-o  them  f@--cm  @-liat  st@@y,,.dpoiixt  ax,td  that  tlic-@r
                                7               we           tryii-ig,  to  stay,  they                                              @ay-t@ng  it
                                8   reasonably  nicc3.1y.                  7,Y)d     I                           thliy  :Ln-cc@,@iid  to mov,@

                                9   on        with           relatioiisliip.
                                10                      Irh  a             Pc)i,,cit                   orc--  hc@  niz,,de-                a  fair

                                                                                         to
                                                 o--F   tl-,c-iir              C-03L,                                      p@7oc,?         for

                                12         17                                                                        k.:z:.e   @i      at  ineralv

                                13
                                                            do                                                            the

                                14                                     Dr.                                                                           nor.
                                15  so       -,uro           h,@  k,.,io!is  how  -Lo  c,-@rrc-c-c                         ein           so  sure,  ii-izit--

                                16  piiy,@o0y                   ho-.@,,  to  co-.--rc-cL-              Evt  it  is
                                17             h-c         do@nc      @,7ith       his             in  helping  other  p@Dopif,-  g  t
                                181                              of-@            g-o-urid,         But  it   1-i   r@   iio-'(--                   the

                                19                        for  Pt@4LP  .,-ri  O:cogon                  it                    hz4vo

                                20                      1    CIO,-to    all    that     by     sayi)-ig     I     @.j@..s     very


                                21  this


                                                        DP,.    lil@ YE P,
                                22
                                                                                                      do     you     h@,,ve,


                                23                      MPN,.   l,',r) 0 RI', -   l@o.

                                24                                              Phi.1,       your       rc...cocTf@--ida-LL.

    !%cc - Fcd(,.iai Repo,,ters, Inc.
                                25                      D  P,.      1 T E  :    @,i7ell-,  @@.s  I  m--ntic)ned,  the  1,,,,ajor  problem









                                                                             110



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

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

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

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

                5 visitors felt that.

                6           There were things on th6horizion -- these  television

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

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

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

              10  able to spend that amount of money that quickly,

              11            We recommended, therefore, a reduction in this to

              12  about $250,000 for each of the second and third  years.  They
              13  did not ask for developmental funds the first year, so we  have
              14  recommended they get what they asked the first year; that  each

              15  of the second and third years they get reduced growth funds
              16  plus their developmental components and instead of $1,588,000
              17  the second year, we have recommended $1,063,000, the third
              18  year in contrast to $1.6 million, we recommended $1.52 million.
              19            DR. l@IAYER:  That is in the form of a motion?
              20            DR.WHITE:  I would move the adoption of that.

              21            DR. THURMAN:  Second.
              221           DR.MAYER: Questions or comments  by  the  co=ittee?
              23            DR. HIN14AN: Do you want me to comment on the  kidney

                  now?
              24








                I           DR. HINI@L: Because that is included  in  that.

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

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

                4  out there today.

                5           DR.-HINMAN:  Part of this application from Oregon

                6  includes a cadaver organ procurement application.  At the time

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

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

              18  is right in this particular area.

                           .They also-are r
              19                           equesting funds to @,pand  their
              20  transplant capabilities.  The VA hospital in Portland has been
              21  approved to increase its transplant capabilities.  It  is
                  to procure.sufficient organs for the needs of all the residents
              22
              23  in the State, both the veterans and non-veterans.
              24            This was reviewed locally by the RAG and by a
  kce- Federal Reportefs,  Inc. staff group. There was some concern about some of the budgetar-4
              25





                                                                               112


                I  items and recommendation was made that a consultant visit  the

                2  area. And today was the only day in which we  could  arrange
                3  to get more than one of the transplant surgeons who has  had
                4  extensive experience to go up.

                5
                             There were a couple of areas in terms of equipment

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

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

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

                9  anticipation.,that Dr. Belcher will recommend that the program

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

               11  budget items.

               12            So that in your motion,.Dr. White, since it does

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

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

               15  going on today.

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

               17  motion as far as I am concerned.

               .18           DP,. MAYER: I gather-the site visit team from  the
               19  comments in the report had no concerns about the kidney proposa'"@

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

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

               22            DR. HINI@WI:  Dr. Blomquist from our staff was a

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


               24  before  the site visit.

     Idetat Reporters,  Inc.
               25            DR. l@IAYER:  Comments on the motion?





                                                                             113




                             Jerry?

                2            DR. BESSON:  Philt do I understand then for this

                3  fifth year, you are recommending no growth funds?

                4            DR.  WHITE:  No, we are recommending growth funds,

                5  but substantially reduced from their request, Jerry.

                6            DR @IAYER:  Not in the fifth year.

                7            DR. 1,UIITE:, They have. not asked for them in the

                8  fifth year.

                9            DR. BESSON:  I see,

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

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

               12  sixth, used for the sixth year.

               13            DR. I-MITE: Yes.

               14            DR. BESSON:  In reading at least your reiteration

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

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

               17  was the third?


               18            DR. MAYER:  Accessibility.

               19            DR.  WHITE:  Accessibility.

               20            DR. BESSON:  Increased  . access to care     that

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

               22  additional funding of the establishment of a peer review

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

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

  kc   fal  Repotters,  Inc.
               251 by the National Center for the development of such an organizat@





                                                                            114


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

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

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

               5  growth funds for this kind of activity.

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

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

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

              10            DR. MPYER:  Phil, would you aLre to comment on that?

              11            DR. @-MITE: I am sure that they would welcome  this

              12  recommendation.  They are highly interested in  this  area,

              13 and I think if we were to encourage them,  thev  would  became

              14  more active.

              15            DR. Z@IAYER:  Could I raise a comment about the

              16  growth funds and the principles inherent therein?

              17            As we move toward anniversary reviev7, triennial

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

              19 program would hae the option of and has  the  responsibility

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

              21  my understanding when we did that that that provided a
                                                                    of the individ,i
              22  mechanism for requests for new project proposals
              23  regions once they have been fully formulated, fully approved by
              24  the Regional Advisory Group, to find their way to Washington.
  'Ace - edrat Reportefs,  Inc.
              25            And I guess I am caught on the horns of  a  dilemma






                                                                              115


                I of saying, "O.Y,., we are or are not going to  use  that  mechanism

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

                3  component was all about.

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

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

                6  worth of projects that they want to accomplish with the

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

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

                9  review within the triennium of dealing with that.

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

               11  Because  Ithought that is what we were proposing two years

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

               13  direction.

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

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

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

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

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

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

               20  specific projects that are being  generated  which  presumably

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

               22            DR. 14AYER:  But don't they have the option of coming

               23 in  a  year from now and asking for additional  funds  to  accorplis

               24 that?

  %c   al  R@porteis,  Inc.
               25            DR. WHITE:  Surely.  I think they do.







                1            DR.  SPELLIAM:   It seems to me this option would be

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

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

                4  funds, they could still do this because this would not in

                5  that sense be  a  supplement.

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

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

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

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

               10  use this in a slightly different way than developmental funds

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

               12  is going to increase in scope rather than actually developing

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

               14  they hope to fund with this.

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

               16  I made a suggestion which was  unfortunately  not  accepted  by
               17@ this committee or C ouncil that when we see a region that  3'.s
               18  moving in the direction that we are almost  imp--lied  to  say,

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

               2O.that-they be coir.@-rended in some way.  And the only way in which

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

               22  certificate -- is  with  bucks.

               23            I wonder whether this use of  growth  funds  and  our

               24  acceptance of their concept i-7ouldn't be a way of this review

  ce- d,,al Reporters,  Inc.
               25  committee at least indicating to them that, yes, this is a





                                                                      117



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

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

              3  that are going in the totally opposite directi on, and we

              4 would discourage by turning off funds.

              5          This  is a way of supplementing their request.  I

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

              7 it is a good one.

              8          DR. I,IAYER:, O.K., further comments?

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

             10 take advantage of my newness to this committee.

             11          Is there still a distinction between this term

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

             1 3component?

             1 4         DR. IAAYER:  I have no problem with that because I

             15 think that what they are saying is in te @ of the developmental,

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

             17 And they are saying that growth fund, if I understand it, Philil-

                    -dollars for new projects
             18 are

             191         DR. I-IHITE:  That's about right.
             20@         DR. @SAYER:  -- as yet not formulat ed in final form,

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

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

             23 of time.

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

 kce- deal Repo(ters, Inc,
             25 justified this in a sense that in the past they have gone






                                                                                118


                 I through this process of developing  an  activity,  a  project,

                 2 but they have been unable to carry it  out  because  of  serious

                 3 restric#--.,,ons on the budget which you are all familiar with

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

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

                 6 people who they need to cooperate with their transportation

                 7 system, peer review system, the family practice clinic system,

                 8 to go along with the whole idea.

                 9           I can see this point. On  the  airplane  out,  I  felt

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

               11  felt just like you.  once they developed something, they come

               12  back next year and ask for support for it.  But after talking

               13  with.them, I understand their viewpoint ind feel perhaps there

               14  is some legitimacy of awarding them these growth funds,

               15  particularly since I think all of the   site visitors were

               16.partictlarly struck with the  quality  of  the  people  involve

               1 7 in this area.

               18            DR. nzYER:  I guess I.have to ask the question of
               19  staff as to whether this is or is  not  within  existing  policy
               20  of the RAG and whether this is a policy issue that ought to be

               21  surfaced. I am not saying pro or con,  Phil,  in  terms  of  the
               22  approach because I think philosophically, I am in agreement
               23  with the approach.  But I am not sure that that is not a-p6licy
               24  issue as opposed to a request issue.

  %C   ral Repoiteis, Inc.
               25            MRS. KYTTLE:  Dr. Mayer.






                                                                               119



                I            DR. IIAYER:  Yes.  Mrs. Kyttle.

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

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

                4 that says unless the review procedures  have  stipulated  to  the

                5 contrary when regions enter a  triennium,  the  approved  levels

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

                7 years of the triennium.

                8            'K7e had to move to that because Oregon, like  several

                9 other regions proposing  a  triennium,  particularly  in  your

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

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

               12 was attempting to establish a level  for  its  triennial  period
               .13 within which it could move in its triennium.  That is the

               14 concept of the approved triennium.

               15            And yet, these regions when they map out their seco,-idli

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

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

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

               19 unless there is a certain reason for  a  decreasing  level  in

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

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

               22 approved level for the remaining years of the triennium.

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

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

  @ce -Federal R@porters,  Inc.
               25 option now no longer possible vis-a-vis the action of the





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                I council?

                2            MRS. KYTTLE:  O.K., within the action of the Council

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

                6
                  staff anniversary review panel considers and reports to you

                7 about.

                8            Should they request the use of  dollars  beyond  that

                9 level, then that would come to committee for action.

               10            DR. I.IAYER:  But that option is still available.

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

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

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

               14 anniversary review panel recommends that that level be
               15 increased.   And I think last time 'Tri-State was one that came

               1.6 to committee because staff  was  recommending  the  second  year

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

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

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

               20 did, provide'grov;th funds, you remember  Ilestern  Pennsylvania

               2 1did it when they went to triennium.  They were trying to

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

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

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




                                                                                                                                                             121


                                 1     tha@  I  have  raised,  though.

                                 2                        DR.  I,,IHITE:    No,,   I            am  not  sure  that  is  correct.    At

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

                                 4    shall  be  not  less  than  the


                                 5                        DR.  MAYER:    Let  me  try  it  again.

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

                                 7    this  one  increases.

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

                                 9                        DR.  SPELL@IAN:     Is  that  what  you  said?

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

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

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

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

                                                                                                                                                                       C-
                              14                          DR.  MAYER:    But  that  doesn't  answer  the  question  whi

                              151  I  raised  which  is  what  is  existing-policy  of  the  Council  in

                              16    terms  of  this  group  taking  action  on  providing  contingency

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

                              18   what  it  is  going    to  be  used  for.

                              19                          DR.  SCIII,IIDT:     You  are  saying  it  is  a  new  way  to  got

                              20      money.     Is  that  what  you  are  saying?

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

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

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

                              24      Council  policy  on  the  point  that  you  are  raising.    And  at  this

               al @eporters,  Inc.
                              25      Point-in  time,   the  concept  of  developmental  components  and  gro,,i






                                                                                  122


                    funds which has been coming into it   has not been fully assessed
                2   by staff.  This is one of our agenda items because we are

                3
                    getting into various ways of providing flexibility to the

                4
                    region.  So it is appropriate at this committee meeting to
                5   make whatever recommendation you want  to  the  Council,  and  they

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

                7   various ways of funding.

                8
                              But you are not inhibited  at this point in time

                9
                    from recommending favorable action on  growth  funds  if  you  so

               10   desire and to recommend different levels of funding for the

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

               13
                    is restrictive.  Both this committee and the    CoLincil may  set

               14   whatever levels for the individual years are    decided upon*
               15   It is just thatunless special action is taken by the Council,

               16   then a level is fixed.

               17             DR. 14AYER:  Let me try it once mo  re with  my  problem.
               18   @ly problem is I sit here knowing a year and a half of     effort
               19   and energy of a lot ofpeople went into establishing the
               20   policy of the developmental  component.  And  I  think  that  was
               21@  appropriate because out of that came  son,.e'guidelines  that  were
               22   known to everyone in the world about what developmental

               23   component is.

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

  @c    al Reporteis,  Inc.
               25   saying is to me that sounds like it is as  every  bit  as  big,  if





                                                                                123


                I not-a larger, policy issu- than  tlie.  developmental  component.

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

                3 just want to get it fla god as an issue  that  ought  to  be
                4 looked at and guidelines established  rather  than  doing  it  on

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

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

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

                8  to do this.

                9            I should say that although the concept of development

               10 component vlas clear at one time which r,,eant that  there  would

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

               12  moves into the triennial period and where  there  has  been

               13. responsibility delegated to the region for funding projects

               14  within the Council-approved program  without  coming  back  and-

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

               16  funds are being provided because the developmental component is

               17  awarded, the concept of developmental component  lies  been

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

               19  have  indicated it was when it was first enunciated.

               20            Many times we approve the developmental component

               21  without additional funds which gives them a flexibility within

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

               23  they have practically all the flexibility  that  they  need

               24  within their program.. And the whole concept of v,,Iiat  develop-
  kc   a[ Reporters,  Inc.
               25 Imental component is actually accomplishing under a level budget





                                                                                 124



                1 is quite different than what it  was  under  a  rising  budget.

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

                3             And it is further complicated by this new concept of

                4  growth funding that has come in.

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

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

                7  clear statement policy.  These things have ye  t to  be  done.

                8  So you are free to flag the issue, and we will be coming to
                9 this as quickly as we can. But  we  don't  have  a  policy  for
               10 you, and Council doesn't have a policy that  I  know  of  at  this

               11  particular point in tire.

               12             DR. MAYER:  Phil.
               13'            DR. WIIITE:  I think it is worth bringing to Councillsl

               14  attention, and I think it is worth pointing out that this regioi-i,
               15 land I hope all, are full of integrity and   honesty, but they
               16  lcould  haveIsaid these are projects we  are  going  to  undertake,

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

               18 precisely what we are going to-do, and put down a budget and

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

               20 and said, "We are going to move  in  these  directions,  we  don't
               21 yet know what it is going to cost,  and  this  is  our  estimate."
               22             Their estimate varies from ours a bit, but I think

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

               24  circumstances.

  ;ce-Fedeial Reporters,  Inc.
               25             DR. MAYER:  O.K., other comments?





                                                                               125



                1            MRS, KYTTLE:  Just one, please, on triennium.

                2            When we first defined the status of  triennium,  we

                3                                                     dy and  that
                  said that  it declared a region as an accredited bo

                4  it could move in this triennium.

                5            Now, following that, the region needs some commitment

                6 of financial stability through these  three  years.  And  that

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

                8 established for the beginning of this triennium should not

                9 decrease during that triennium unless there are specific reasons,

               10 for it.

                             DR. IIAYER: We have no problem with that,  Lo--raine.

               12 I think that is a second issue.

               13            Yes, Mrs. Silsbee.

               14            MRS. SILSBET: As I hear it, though, I  think  if  you
               151 decide you are not going to have any growth fun ds, the
               16  level would automatically go down in this particular instance,

               17            And while we don't have a Council policy, the discuss4-,

               18 of Council at the time Western Pennsylvania proposed this very

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

               20 very clear that Council knew what they were  doing  here,  and
               21 they did agree to that as a concept.  And  they  approved  it.

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

               23            Jerry?

               24            DR. BESSON: We have cuTotion on the floor  to  accept

  kc   al Repofters,  Inc.
               25  the recommendations of the site visit team.  And I wonder if





                                                                             126



                                                                           inp'in-'
                I I could wnend that since this may be a focal point for p    0
                2 this question, the amendment to include something  to  this
                3 effect that where a region shows evidence  of  implementing
                4 policies which are concurrent with it@ stated goals and
                5 priorities and also consonant with national priorities, that in
                6 order to encourage'its expansion in this direction, growth
                7 funds may be awarded on application at the discretion  of  the

                8 Council.

                9           DR. MAYER: And upon recommendation  of  the  review

              10  committee?

              11            DR. BESSON:  Yes.

              12            DR. SPELLI,@l:  I would agree with that in principle.

              13 @id I think taking what Judy has said and what  Herb  said,  if
              14  increasingly devel opmbntal funds are being used  as  growth
              15  funds which is really what  I understand you to have  said,

              16  the flexibility is even greater than was intended.  Tien, you
              17  might just as well drop any distinctions between developmental
              18 and growth funds and call it by a single name  and  let  the
              19 full amount then bear some relationship  to  the  difference

              20  between the level of funding in the first, second,  and  third
              21  year rather than that very modest increment  in  development.
              22  funds.  Because, again, you see, if he calls this developmental

              23  funds by tradition or whatever, he is limited to  a  pretty
              24  small amount. But by adding growth, he has  an  amount  there

       al Reporters,  Inc.
              25  that is almost a fourth of the total level of funding.





                                                                           127


                I           So X think you might consider now adopting a

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

                3 increment above the first level of funding.  it Nvouldn't make

                4 any difference there, and that would @al-@e care of vihat,everybod@

                5 is talking about.

                6           DR. @IAYER:  Could the chair try to separate these

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

                8 the individual proposal and then deal with the policy issue

                9 if we could.

              10            DR. BESSON:  Then I will withdraw.

              11            DR. I.IAYER:  Because you may find yourself in a

              12 position of having to vote against the recommendation that

              13 you might agree with because you are disagreeing  with  the

              14 principle.  And I think that would be inappropriate.

              15            DR. BESSON:  O.K.

              16            DR.  I,,IAYER:  Further comment on the recommendation
              .17 lof the site visitors relative to the funding and level  of

              18 funding for the Oregon PJ4P?

              19            MR. 110ORE:  I would like to add one point.


              20            DR.' @IAYER:  Yes, Mr. Moore.

              21            MR. @IOORE:  Of the seven growth fund activities they

              22 are  presently participating in five as a part of  planning

              23 feasibility and core activities.  So these are not new

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

  ce   I Reporters,  Inc.
              25 should the feasibility planning studies grow to a point of




                                                                               128



                  projects in the following years, then they would be

                2 submitting such projects,

                3            DR. 1,MYER:  Further comments?


                4            (No response.)

                5            Everyone clear on the motion-and recommendation?

                6            All those in favor say, "Aye."

                7            (Chorus of ayes.)

                8            Opposed?

                9            (No response.)

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

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

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

              13  obvious one.  I just have a feeling that the implications
              14  of that are moderately significant in term of how people chanczd

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

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

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

              18  flag of the policy issue in suggesting that an appropriate

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

              20  least to suggest that representation on that group come off

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

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

              .23 is as simple as you say.
              24             DR. BESSON:  In the interests of being even-handed

  @Ce eal R@portefs,  Inc.
              25  with the bandying about of the notion of emasculation, I think





                                                                              129



                I putting some -- I will block that metaphor that just cam,-- to

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

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

                4  fund separate.

                5           Let me reintroduce my motion. But I  would  like  to
                6  keep it separate from the developmental component  mentioned

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

                9  committee by its action can tend to move this ponderous
              10   machine in one direction or another, then the use of  growth

                   funds can be what we used to do many years ago in awarding

              12   funds for projects -- encouraging those that we said yea  to

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

                   longer do.  All we can do is award a lump sum and approve
              14

                   general principles and process.
              15
              16            But this might allow us to indicate to a  region that.-
              171 yes, they are doing what they should be doing and to other
              18   regions that get zero growth funds, that can be a very obvious
              19   sign to them that maybe this review committee and the general

                   direction therefore for how R,114Ps should develop may be somewhat
              20

                   more re-established.
              21
              22            DR. SPELUIAN: I would just answer  that  by  saying
                   that I think the differences between what the growth fund
              23
                   and the developmental component are going to be used for  in
              24
  -ce   I  Repofters,  Inc. the future could be increasingly artificial. If you look  at
              25




                                                                           130


                  that, it is only 13 percent different between the first and

                2 second year.

                3           What this means is this is just an assurance  to

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

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

                6 are going to do with that increment. That is all  it  is.  And
                7 I wonder, what Herb said, if people are already doing this

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

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

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

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

              12  the only point I make.

              13            DR. MAYER:  Joe.

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

              15  here, I have wondered how much of this problem would have  been
              16  eliminated if they had just not put in those two words  "growth

              17  funds," and left those projects listed under the headings  and

              18  money attached to it and left the developmental component  just

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

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

              21  gone on?
              22            DR. MAYER: If you are saying if they  had  formulated

              23  projects that were there that the site visitors felt  were

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

  %ce eal Repofters,  Inc.
              25  gone through the internal review process, I would have  no

                 I






                                                                             13 1


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

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

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

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

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

               6   ideas that we have that are partially formulated that we

               7   think are appropriate to be in-tlic regions that we are  going

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

               9   different thing than developmental component which is sort of

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

               11  even been thought about yet.

               12            DR. SPELU.IAN: But the evidence I gather is  that

               13  the differences between these are rapidly fading and indis-

               14  tinguishable from what he tells me. The  question  is  really-
               15  two years from now whether we viill be able to tell them in

               16  Oregon what is the difference between the way they use  the
               17  $75,000 and the $250,000.  They may lose their definition.  Tha@,

               18  is all.

               19            But I can in agreement with the principle that  thev
               20  ought to have $75,000 plus the $250,000.  I was just suggesting
               21  that it be done in a way which in the future would make  it  a
               22  lot less complicated than inventing nomenclature that is just
               23  meaningless.  It is the way of getting more money for the

               24  second and third year.

  %C   al Reporters, Inc.
               25            DR. 14AYER:  Maybe it goes something like this -- let





                                                                              132



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

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

               3  that if definitive policies are to be established relative  to

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

               5  the committee expresses its desire to participate in those

               6  decision-making processes,

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

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

               9  no longer have control.

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

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

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

              13  growth ft,-nds are good, they think it is appropriate, but.it

              14  finally dawns on them that unless they start as in all  things

              15  to further define what the boundaries of growth funds are,

              16  what percentages might be appropriate, da-da, da-da, da-da,

              17  when they do that, all I am saying is we ought to  participate

              18  or representatives of this committee in the future ought to

              19  participate in those discussions.

              20            Yet, Leonard.

              21            DR. SCHERLIS: Maybe I am hypoglycemic, and  I  don't

              22 quite know why I feel as I do about it, but I really  think  we

              23 are raising issues that we are looking to raise in this regard.

              24  I would much prefer that the site visitors give us a

  4ce eral Pbporteis,  Inc.
              25  recommendation that certain priorities have been set up  which





                                                                              13 3



                  obviously require certain funds of money.  And it is
               2  apparent that the money will be spent in that area.
               3            1 don't like the term "growth" now.  We are going to

               4
                  have to define it as distinguished from developmental.
               5            Maybe I am the only one who has the limitation of
               6  trying.to distinguish between these two terms.  I would much
               7  prefer we keep the developmental as it is and  just  ask  for

               8
                  a little better definition of how they are spending the money.

               9
                            You have defined it. You said  seven  areas  they  are

               10 moving into.  They have  already moved into five,  they  need

               11 the funds to move into the other two.  After all, I would just
               12 say they found some money, that is what they are   .going to  do,

               1 3and they defined it pretty well,

               14           I would hate to see us  telling Council when they have

               15 reached a decision they have got  to come back to us, and we will@

               16 discuss it further. I don't think a  decision  is  necessary  in

               17 this regard.

               18           1 would move to strike out the last ten'minutes of

               19 discussion.

               20           DR.' MAYER:  Joe.

               21           DR. HESS:  I think we may well be creating an

               22 issue that doesn't need to be created  here.  If  we  understand

               23 what they want to do, because they happen to use a couple of

               24 words that were unfamiliar to us, let's not get  hung  up  on

  kce   I Reporters,  Inc.
               25 formulating a brand new policy.   It seems to me this  could  be
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               I  handled under existing policy of a region who has reached

               2  the triennial status.

               3            DR. MAYER:  There is more than just the wordst Joe.

               4  There is some substan tive difference between  this  approach

               5  and other approaches of definitive projects.  And I won't say

               6  anything more about it.

               7            DR. SPELLIIAN:  If it is that simple, you can predict

               8  that everybody will do  that.

               9            DR. BESSON:   I think everybody else might  have  the

               .10 option of doing  it.

               11           At the risk of prolonging this discussion at an

               12 inappropriate blood sugar level time, and many decisions we

               13 may make are based on no more influence than  that,  I  would

               14 say that I see a difference. And I think  that  a  13  percent.

               15 increment you referred to, implying that therefore  it  is  not

               16 very different from the developmental component    I think  I

               17 read somewhat differently here, 14itch, because I see that that

               18 13 p--rcent'increase is a result of a 24 percent decrease in

               19 projects and an 18 percent decrease in core,  but  100  percent

               20 increase in growth funds.

               21           Now, that gives you a figure which is  not  far  from
               22 the developmental component. But the point  is  I  don't  think
               23 that  10 percent is adequate enough for what some regions want

               24 to do in an expansion4-ng fashion.  The growth fund concept,

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                                                                           135



                I  a region that is moving in the right direction to really

                2  blossom.

                3           Right now it is constrained from so doincj..by having

                4  a limitation of 10 percent on it.

                5           DR. MAYER:  O.K., I guess the question I have to

                6  ask is, we have taken.an action on one which does have this

                7  principle that would suggest we are in favor of it, at least

                8  as it relates to Oregon, and we have no'objections to the

                9  principle at least as it applies to Oregon.  I guess the

              10  question I want to raise is do we want to make any comments

              11  above and beyond that of a more generic nature to Council?

              12  And if we dot what is it? And if we don't, then,  fine,  let's

              13  end the discussion.


              14            Mac,

              15            DR. SCHNIIDT:  I believe 'we should comment that it

              16  seems apparent there is some change in the concept behind  the

              17  developmental component and the growth fund concept is  worthy

              18  of study in relation to the other. And the staff  and  Council

              19  should take this under advisement and so on.

              20            I think both of them have to be looked at in relation!;

              21  to each other and something new developed,

              22            I personally favor a single type of dollar.  And I am

              23  really closer, I think, with Leonard than anybody else.

              24            DR. BESSON: I withdraw my motion in favor  of  that.

  ,C, "al Repotters,  Inc.
              25            DR. SC@IIDT: I would move the sense of  whatever  it

















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                                                                             137



                 I                      AFTERNOON SESSION


                 2                                           (1:40 p.m.)

                 3           DR. MAYER:   What I would       to do sequentially  as

                 4  a  tentative agenda is go down the list  mid pick up Ohio and

                 5  then pick up Northeast Ohio which is in  a way linked,  then

                 6 go back up to Nassau-Suffolk and  to  Nebraska  sequentially.

                 7 And that gives John a chance to settle in before  he  has  to

                 8 go to  bat.

                 9           DR. KRALEWSKI-.  Thank you.

               .10           DR. 14AYER:  And I assume that you all followed the

               11 explicit instructions given just before  breaking  for  lunch  to

               12 use part of your lunch break to  complete  the  rating  sheets

               13 on Oregon. If you did not do so,  let's  take  a  couple  seconds

               14  and do that now because I am afraid if we wait after we start in

               15  another one that things may get a little fuzzy.

               16            Vlhat we are turning to, then, is the new Ohio

               17  Regional Medical Program.  I'am the primary reviewer, Mr.

               18  Hilton is back-up reviewer on it.

               19            Let me comment in way of introduction about this one,

               20  Phil said or someone said earlier you ought not to make

               21  apologies, but I really feel that I have got to make some

               22  disclaimers at the outset on this one because  after  six  years

               23  and six months of involvement in one way or another with  IU,IP,
               24  staff somehow seemed to have saved the toughest task that I

  %C   a[  Reporters,  Inc
                 ' have had to the last day of my service.  For what they have
               25





                                                                              138


                I done is given me the opportunity, if you can call  it  that,
                2 without benefit of site visit or personal involvement six
                3 years after the funding of the first RMPs what is essentially

                4
                  a new JU4P to review by guidelines which are long since  moved

                5
                  on to other kinds of things.

                6
                            At this stage in the developmentr we  are  supposed

                7 to be looking at total programs and not  individual  projects.
                8 Yet, there is as yet no really total program  existent  here.

                9           At the same time, there was a mandate from  us  and

              10  Council that they try in the Ohio Region to put two  or  more

              11  of those individual P-%IPs together because of their poor

              12  quality to dater at least the three of them, and  they  have

              13  done that, at least with two of the programs.  our advice and

              14  counsel are to go up to the National Advisory  Council,  two

              15  of whom whose most sophisticated and  long-standing  members,

              16  Bruce Everist and Clark 14illikan, have trod this sod which  I

              17  have not.trod in January, and they obviously, I suspect, have

              18  some preconceived ideas about what ought to be done  in  the

              19  area.

              20,           If there has ever been a setup to wipe  out  itself

              21  on this one, and I can see the headlines now, "Mayer goes down

              22  in flames on final mission."

              23            To cap it all off, I am-not sure how  much  advanced

              24  notice Mr. Hilton had.  At least in the previous communications
  kc   al R@porters,  Inc.
              25  that 1 had, it didn't appear there was a secondary reviewer on




                                                                             139



               I this. And so I really think it is going  to  be,  "Mayer  goes

               2  down alone in flames on final mission."

               3             So I commence this review knowing I picked up  an

               4  assignment befitting a chapter in "Mission  Impossible,"  and

               5  wishing that not only my instructions might  have  self-destructe(

               6  but the whole region from Athens to Zanesville.

               7             As a background, you,will know, as you recall  in

               8  previous meetings, we felt that although the State  of  Ohio

               9  might be the mother of Presidents, we hardly felt it  was  the

               10 father of RMPS. There were four @iPs involved  in  the  State

               11 the Ohio State @IP which was focused out of Columbus, the

               12 Northwest Ohio @IP focused out of Toledo, Northeast Ohio  RYIP

               13- focused out of Cleveland, and then the  Ohio  Valley-Kentucky

               14 PIIP focused in Kentucky and including Cincinnati and the

               15 several-county area in southwest Ohio.

               16            The first three, to put it mildly, had a great deal

               17 to be desired.  And it was suggested by staff and by ourselves

               18 and Council that we might be able to put some bad apples

               19 together and with appropriate aging come up with  a  vintage

               20 wine rather than some sour cider.  I am not sure how

                         iate that decision was, but tha- was the  decision  we
               21 appropr

               22 Made.
               231           Accordingly, in the April-may review cycle of  last   i
               24 year when we had all of the bad apples together from  Ohio  in

      eal Reporters, Inc.
               25 the review process, we extended their funding for an  abbreviated





                                                                                 14 0


                   period from July of last year to January to provide them the
                2  opportunity to get together. This  they  did  with  the  following

                3
                   results:

                4             It looked like the Ohio State -- I think if you
                5  will take  your yellow sheets, page 7, there is  a  map  which
                6  outlines the region.  It gives you some feel for the geography.
                7 lihat appeared was that the Ohio State MIP  which  is  central  and
                8  southeast Ohio and the Northwest Ohio @IP were making music
                9  together, but the Northeast RMP really  was  keeping  out  and
               10  saying they wanted no part of those other two.  And really,
               11  the Ohio Valley P.I@IP which incorporated the southwest  component
               12  of it was never really a ma)or part of the issue, feeling
               13  they probably were a functional RMP and it may not be

               14  appropriate to try to get them involved.

               15             So we extended them for six more months from

               1.6 January to July after having extended  them  six  months  from
               17  July to January to try to work that out, then extended them
               18  another  six months and then sent the shock troops of  @lilli):an,

               19  Everist, and staff in on January 10 and 11 as a fact-finding

               20  activity relative to the three regions.

               21             The results of that visit are outlined in the

               22  %,ery poignant comments of Millikan and Everist on pages 27 to
               23  35 of the yellow sheets.  I recommend those to you as reading
               24 programs tonight because I think  they  are  cia--sic  examples

  @ce  ,al Reportefs,  Inc.
               25  of what two pros can surface in just two  days  in  a  region.




                                                                                   141



                 I            In brief, they,-.however, discovered the  follo@,7ing:

                 2 That Ohio State and Northwest Ohio  Pj4Ps  were  making  progress

                 3 towards union and Northeast Ohio in its pristine purity was
                 4 having none of it.  And although they had invited-the Ohio

                 5 Valley-Kentucky groups to participate,  they  felt  that  it  was

                 6 probably not appropriate to incorporate them in it.

                 7            The end result was  a  series  of  recommendations  that

                 8 came out of the February 172 issues of Council which are on

                 9 page 2 of your yellow sheets.  And I will not go through those

               10  in any detail, but essentially I think did recommend the

               11  formation of a new P,14P which c @ined the Ohio State with

               12  Northwestern regions and that the effective date of merger
               13@l be September 1 and that  this  application  of  that  merged,  two.
               14  merged PIAPS, are to be brought  back  to  this  particular  review

               15  cycle.

               16             Well, that is the  background of this  particular

               17  application.  And what do we   have in it?  We  have  a  proposal

               18  then to merge previously existing Ohio State and Northwest

               19  Ohio M.lPs into the Ohio Regional Medical Program.
               201            We have a request for $2,082,000 in direct costs for

               21  one year activity when as near as I  can  figure  out  from  data

               22  which are not totally   complete, they are roughly at a $1.4

               23  level of activity in that.

               24             The request includes a request  for  $1.2  million  of

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               25  program staff, a core, compared to a current combined total





                                                                                  142



                 I  of about $800,000 now in core.

                 2            We have a request of approximately $800,000 of

                 3  project funding which include the following:

                 4            Onet two projects, the first  and  second  ones  there

                 5 which have previous Council  support  for  approva@  for  support

                 6  for an additional year.

                 7            Two, a kidney project in  the  amount  of  $201,000

                 8 that is project three -- which will  be  reviewed  on  May  8.

                 9 And since this is May 4. I don't  know  what  that  review  has

               10  in   common.

               11             And thirdly, there are 12  other  new  projects,  nine

               12 of  which  are  from  the  previously,existing  Northwest  Ohio

               .13 P@IP and three from the previously  existing  activity  in  the

               14  Ohio State IU4P. And when I am  saying  nine  in  that  Northwest

               15  Ohio P,'L@IP, I have to comment parenthetically there has  been

               1,6 a considerable amount of  concern  that  previous  activities  in

               17  the Northwest Ohio P14P were moving towards  the  funding  of  the

               18  newly developed medical school-at Toledo with emphasis on that

               19  rather than to a greater degree on the RMP component.

               20             And, finally, one out of the 12  that  is  a  health

               21  careers program of Ohio in  the  amount  of  $171,000  outside  of

               22  RMP guidelines.  And that is contained on page 17 of the

               23  yellow sheets as to why.

               24             In my opinion, then, they  have  made  progress  in

  @ce   I Reporters,  Inc.
               25 merger. They did  attempt  as  requested  by  Council.to  move  the
                  I





                                                                             143


                I Northeast Ohio and Ohio Valley        However, this whole

                2 application has the flavor of a new and  developing  region.

                3 And it kind of has the deja vu of four to five years ago.

                4           William Pace, the Dr. William Pace  at@Ohio  State

                5 who is the acting coordinator, obviously has had a great

                6 impact in trying'to bring this merger about and has obviously
                7 been helpful in Pffecting it. However, he is' pulling  out  or

                8 resigning on June 30 of this year, and  they are looqing for

                9 a now coordinator. The reasons why Dr. Pace is  -leaving  that

              '10 responsibility aren't clear, and perhaps staff may  have  some

              11  comment on that that may be helpful to us.

                            Secondly, in terms of the review process at the

              13  regional  level, this appliation is acknowledged by them  to

              14  essentially having been nonreviewed in the kind of review

              15  process that they would hope to ultimately accomplish  in  a

              16  combined region due to the newness of the effort.
              171           Thirdly, the goals  and priorities of the group  are
              18  general, not specific, but tJiey do have a mechanism and are

              19  actively, I gather, working on them.

              20,           Fourthly, the advisory council is temporary  and  is

              21  in the process of -- this is the combined  advisory  council

              22  expansion in organization.

              23            Fifthly, the staff is not yet fully formulated or

              24  organized although there is a fairly good proposal for

  ce  e",l Reporters,  Inc.
              25  organization that is contained in the  application  activity




                                                                            14 4



                  materials. They now have, as I gather, 19  professionals  in

               2  the two pre-existing programs, 13 in Ohio State and 6  in

               3  Northwest Ohio, and are requesting 32 professionals in  the

               4  core staff and the new development, an increase of 13.

               5            Sixthly, they have agreed on a grantee and a  fiscal
               6  agent, the Ohio State University Research Foundation,  which

               7  is evidently a private corporation which is handling  the

               8  research funds of Ohio State in the amount this year of

               9  around $20 million and obviously have competency at the

              10  fiscal level to handle the activity.

              11            And, finally, they evidently have settled in  a

              12  positive light on a relatively strong RAG chairman in the form

              13  of Dr. Brain Bradford of Toledo.

              14            So that's where we are. And I suspect  you  can

              15  understand part of my problem that.I tried to outline at the

              16 beginning of the presentation. When I got to  this  stage  of

              17  the report, debating about what to conclude about all of  this

              18  in light of the newness of the activity when most  programs

              19  have moved on in a far more sophisticated fashion, I  recall

              20  John Gardner@s beautiful essay on the anti-leadership  vaccine
              21  which some of you may have read.  And it is in the part %,7h-..
              22  he was describing one of the great dilemmas of the day  and
              23  problems of today is the lack of any real confidence in  the
              24  leaders of today    that is, confidence in their capacity to

  ce   I Reporters,  tnc.
              25  perform and assume responsibility.







                             When he was talking about it, lie described  the

                2 story of the little girl in the third grade art  class  who  was
                3 asked by the teacher,, "What are you drawing,, Mary?"  To  which

                4  Mary replied, "I am drawing a picture of God."  And the
                5 teacher then said, "But, Mary, no one knows  what  God  looks
                6  like."  Mary simply said, "They will when I get through."
                7            So what I am about to tell you is I have  no  idea
                8 in my own mind really what is the appropriate  way  of  going

                9 about evaluating this activity. We have  an  example  of  two
               10  regions which have a poor track record in terms of what they

               11  have accomplished in the past.  We have told them to merge.
               12  They have done that and have done that with, as  I  gather
               13, reading between the lines, a fair amount of pain, but neverthe-
               14  less have accomplished it and do look like they  are  beginning
               15  to move in appropriate directions.
                             So that is where it is.  And I guess it is out of
               16
               17  that kind of anxiety and concern that I will  blithely  go
               18  ahead and give some conclusions about recommendations about the

               19  activity.
               20            As I indicated before, the funding, as near as we
               21  can get an estimate. of the program support of core  staff
                   of the two programs together, is about $811,000 on an annual
               22
               23  basis., I would recommend funding them at about $900,000 for
               24  the first year which is roughly a 10 percent  increase  with

  %c   ral Reportefs,  Inc.
               25  recommendation for second year funding about 1.0 percent  above





                                                                          146


                I  that or at the roughly $990,000 level.  This does, then,

                2 at least give them an opportunity to try to take the  steps

                3 of putting the two programs together and building a  strong

                4 and effective core staff.

                5           They are currently funded at about $583,000 in terms

                6 of individual projects and are asking approximately $800,000

                7 for individual projects in this.  And I would.recommend a

                8 level not to exceed $500,00 0 in project activity with a

                9 minimum of 5 percent increase in the second year.

              10            Included in that funding of individual projects

              11  obviously is the continuing commitment of the funding of

              12  projects 1 and 2 which have already been approved if they so

              13  desire   And included in 2, is the funding of the renal

              14  project if approved by the ad hoc panel. And if it  is  not

                  approved by the ad hoc pane@, then'I would suggest a reduction
              15

              16  of that amount from the $500,000 that I recommended  above,

                            And then, fifthly, obviously excluded from approval
              17

                  for them to spend any of their money on what would'be project 8.
              18

              19  which is outside the guidelines of the RMP.
              20            Ande finally, I v7ould suggest that we indicate to
              21  Clark Millikan and Bruce Everist at Council level that I

                  this project for the review committee and suggest at  least
              22
              23  that my tour of duty with P24P, at least at this point in time,

                  at least equals or exceeds theirs, so when th ey get to alter
              24

       at  Reporters,  Inc
                ' these recommendations at the Council level they at least know
              25





                                                                              147


                1  whose recommendations they altered.

                2            Mr. Hilton, comment?

                3            MR. HILTON:  In view of the weak history of the

                4  Northwest Ohio Regional Medical Program and the  Ohio  Regional

                5  Medical Program prior to its consolidation, it might be

                6  appropriate to ask whether encouraging consolidation would
                7  really amount to lumping together weak programs in order to

                8
                   create a larger weak,program. I think that is  the  dilemma  we

                9  are facing right now, and vie don't really know what with  the

               10  vacancy in the coordinator position and some of the other

               11  things that are on the horizon.

               12            However, I was positively affected by the documentatic

               13  on this program. The statements of by-la@qs and  very  detailed

               14  descriptions of administrative procedures which will be

               15  implemented in this new, first operational year of the new

               1 6

               17            The R!,P- recognized that consolidation really has

               18  been against the background of its history its major accomplish-!

               19  ment for the last year. It also concedes that  it  has  taken-a

               20  good deal of time, staff time, and energy.

               21            They face a problem, looking to this first  year,  I

               22  think, a dilemma which was described in one of  the  documents

               23  I read whether they should devote themselves  aggressively  to

               24  piaqning and development activities in light of this new
       Ial Rbporteis, Inc.
               25  consolidation effort or whether they should  launch  apparently




                                                                             148



                  a real active involvement in new projects. I  don't  think  it

               2 was really an either/or position. They  opted  for  the  active

               3  involvement in projects which I had the feeling would  not  be

               4  appropriate. And so I totally agree with Dr. Mayers' suggestion

               5  they not be funded to launch all those projects.

               6            1 think there still remains to be  enough  uncertainty

               7  about what would happen with the new coordinator.  And  I  think

               8  we are really inviting a situation where the body  controls  the

               9  head to have this much predetermined before a new coordinator

               I 0could be hired,

               11           I was impressed by the participatory RAG or what they
               121call.their Regional Advisory Council, Regional  Advisory  Group.
               13 Apparently that body participates fully and actively.  And

               14 there are some innovative ways in which RAG members will be

               15 able to through task forces continually monitor  the  progress

               16 of staff tc,@iard consummation of projects that have been

               17 proposed for the area.

               18           Some of the things that worried me -- I  have  alluded

               19 to one already, and that is not knowing the  coordinator  and.

               20 not knowing whether we are really talking now about a larger,

               21 more efficient program, more efficient leadership, or  just  a

               22 larger program.  I was impressed by the efforts to keep the
               23 door open for Northeastern Ohio and even for  Cincinnagi,  which

               24 seems not to be inclined to join the group.

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                                                                            149


                I statistics suggest some 9 percent nonwhite population in Ohio.
                2 Pnd for this region, this new consolidated region in particular
                3 it would probably somewhere in the neighborhood of at least
                4 6 percent minority overall.  But on the staff, some 19
                5 professionals', there are 2 black professional staff. There
                6 are no other nonwhite minorities indicated  in any of the
                7 reports.  And there are 2 blacks on the clerical staff.  I am
                8 uncertain as to the minority input into the RAG.  And planning
                9 committee, I-get numbers that range from 8 to 11 in terms of
              10  participation and no clarity on the degree of participation.
              11            Nor are there any statements indicating any move at

              12  this point to act on that problem.
               .13          The new proDects, 9 new projects that were submitted
              14  aside from the legal point on project No. 8 seem to have
              151 been heavily designed by Northwestern Ohio which originally
              16  covered only 12 counties.  I was concerned whether the smaller
              17  nui,-ber of counties to the extent'that these projects might be
              18  based in those counties should'dominate the entire Ohio
              19  Regional iledical Progran, which the other part of it is 49
              20  counties and really the larger part of the area in question.

              21  So I had some concerns about that.
              22            Aside from that, I think we are put in the position
              23  that we have to accept a good deal  on faith at this point in
              24  time due to incomplete information  and the expectation of
  kce   I @eporters, Inc.
              25  new leadership in this region.  And on that matter,  I would





                                                                              iso


                I have to join Dr. mayer in the uncertainty, but  I  would  agree

                2 perfectly with the recommendations on funding.

                3            DR. MAYER:  O.K., additional comments or

                4 questions.

                5
                           1 DR. ELLIS:  I would like to ask a question.  Are

                6 they working very closely with Comprehensive Planning A

                7 agency? And how are they working with  the  section  in  north-

                8 western Ohio?

                9            DR. MAYER:  Well, I gatlier from the information that

               10 there is a very direct linkage with the B agencies.  I missed

               11 where that link was with the A agencies.  in other words,

               12 they are actually planning to subregionalize the area in accord

               13 with the B agency geographic boundaries and linked to the B

               14 agencies. That is part of  their  whole  organizational  chart.

               15            You all got it.

               16            DR. ELLIS:  I just wondered what you thought about it.!

               17            DR. ILKRGULIES:  Could I comment on that?  Because

               18 Ohio is a  rather unusual situation for CHP.  The  director  of

               19 Comprehensive Health Planning is Sewell Millik.-tn who is on

               20 the National'Advisory Council. And he has  played  one  of  the

               21 key roles in trying to carry this merger through  and  in  fact

               221 in trying to get what we initially were trying to achieve which!

               23 was a merger of all three of the programs which was so far

               24, ineffective.  So that the relationship with the A agency is

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                                                                              151



                I            And then added to that is the fact that the director

                2of the State Department of Health is John Cashman who was

                3  formerly the head of Community Health Services in HSMHA and

                4  has had unusually strong interest in uniting these activities

                5  in Ohio.

                6            So that we are favored regardless of where they are

                7  at the present time with some 'unusually strong elements to

                8         em together better than they would under ordinary
                   pull th

                9  circumstances.

               10            DR. MAYER: What they have programmed,  they  have

               11  programmed a major build-up in the core staff of the  total

               12  region. They have developed two subregional groups  with  the
               13  pre-existing ones, but with small staffs there, two people, I

               14  think, in each one.

               15            And they are proposing then they branch out  from

               1.6 that. For example, the Northwest Ohio Region covers  two  CHP

               17  B agencies.  And they are actually going to put their staffing

               18  in those two B agencies. And the proposal is that  there  are

               19  five 8 agencies relative to the Central Ohio one with a  link

               20  to those five agencies.   Actually it is right on the

               21  organizational chart.

               22            Now, how far they have gone, I don't have a feel for.

               23  But they are at least thinking about those issues.

               24            MISS ANDERSON:  Do they have a competent deputy

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                I            DR. IAAYER: Well, all I can comment is what  I  read.

                2  And the opinion evidently of Millikan and Everist  was  that

                3  the Northwest Ohio existing coordinator was not very effective

                4  and that Pace had proven to be moderately  effective.  And  the

                5  problem is that they are now looking for a leader.

                6            And this is one of the reasons why I personally

                7  suggested that two-year funding for them as a  mechanism  of

                8  at least providing an option for a guy to have two years of

                9  assurance of a chance to build a program.

               10            John.

               11            DR. KRALEIISKI: Are they actively looking for  a  --

               12            DR. MAYER:  Yes.

               13,           DR. KRALE;-ISKI: Everyone that is there knows  that?

               1 4           DR. MAYER: Yes.

               15            Does staff have any further information?

               16            MR. VAN WINKLE: They have  a  search  committee,  and

               17  they actively now have 42 possible candidates for that position,

               18  a sum of 42. Some of them are existing  coordinators  in  other

               19  @MPS who have shown an interest, one being  an  ex-Ohio  State,

               20  or graduate of Ohio State, I might say. And I  believe  he  is

               21  an Ohio boy.

               22            They have hired, it is not really a deputy coordinator-'

               @3  They have a 'three-p--onged organizational chart there.  And

               24  they call them associate coordinators. And  they  have  just

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               25  hired'tlr. Al Deitz who was the Deputy Commissioner  of  Health





                                                                    153


              I  under the Rhodes administration.  And I believe Dr. Ellis

              2  is quite familiar with him.

              3          DR. ELLIS:  Yes, he is good.

              4          I,IR. VAli WTNI@LE;  He is quite an effective administra-

              5 tor.  And he is due to come aboard the first of June.

              6          And Dr. Pace's reason for his stepping out is that

              7 he said that he had 21 years commitment to Ohio State

              8 University, and when it came to making a decision as to

              9 whether we were insistent upon 100 percent coordinator, he had

            -10 to go and stay with Ohio State rather than stay with the @'-IP.

            I I It was his.election that he do that.

            12           DR. MAYER;  John, I think their problem is no one

            13  in their right mind until the Council takes some sort of

            14  action in this sequence, I think would dive into that.  Because

            15  the message that is there is that there have been two N@;eak

            161 programs, and we have told them to do something about it in
            171 terms of merging them.  But they don't have any answer back

            18  about vihether we think there ia a chance.

            19           So I think what is done as action in this next step

            20  is important.  And this is why I put the emphasis on core

            21  staff support as part of the planning and build-up of the

            22  region as opposed to individual project.support.
            23           DR. KRALEIISKI:  That funding that you are suggesting,

            24  e.,hat does that allow them to do?  I am sorry, but I didn't

 ce    I Repotteis,  Inc.
            25  follow that very well.
               I






                                                                             15 4



                            DR. 14AYER:  What it allows them to do, they

               2 currently have about $800,000 in existing core  staff  at  the

               3 expenditure level. My guess is that they  are  going  to  lose
               4  some of those people because of the cfianges that have occurred.

               5  So that there will be some shrinkage and freedom  that  will

               6  be as a result of that.

               7            1 am suggesting another $100,000 internis of  core

               8  staff support for them. 2hd I am  also  suggesting  $500,000

               9  in project support if the renal disease program  is  approve,.

               10 If the renal disease program is not approved, I am recommending

               11 only $300,000 in project support.

               12           Now, if  the renal disease program is not  approved,

               13 that produces an operating budget for next year of.about

               14 $1.2 million as opposed to an existing operating  budget  of

               15 about $1.4 million.

               1.6          Now, of that $1.4 million, a significant  hunk  of

               17 that are projects which are due to be phased  out.  only  two

               18 of those that are there are previously existing projects.

               19           You are caught on the horns of a dilemma.  You provide

               20 a significant increase for two regions who have  not  achieved

               21 on the hopes for the future. And I guess  what  I  am  taking
               22 is a middle road which says provide them approximately what the"

               23 were getting as two separate regions to move forward into the

               24 future to see if they can do something with it.

       al Repofters,  Inc.
               25           Sister Ann.








                I            SISTER AN14 JOSEPHINE: I think it is significant

                2  they are looking for a coordinator of the  Regional  Medical

                3  Program.  And I think there are several other programs that

                4  are probably in that same position. And I think  it  is  not

                5  unrealistic to expect it is going to be difficult from here

                6  on out to get good coordinators of programs.  There is going

                7  to be a lot of interprogram pirating.

                8            And so I think that the national trend that we are

                9  seeing in mergers and consolidations certainly  should  hold
               10  on a.State level.  You know, in California, we could be looking

               11  for eight coordinators.

               12            DR. MAYER:  Other comments?


               1 3           (No response.)

               14            Any additional comments of staff who were  on  the

               15  site visit in Jan uary?

               16            DR. SPELLIIAN:  Is it appropriate to include in the

               17  level of funding a sum v7hich includes the renal project given

               18  the quid--lines we have just had set?  Can we do that?
               19            DR. YAAYFR: Well,, it was included in their  total

               20  tab.

               21            DR. SPELU-IAN:  O.K.

               22            DR. MAYER:  Since that $200,000 was a part of the

               23  $800,000 requested for projects, I dealt with it in that

               24  context.

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               25            DR. HIN14AN:  Do you want any comment on the kidney?






                                                                              156


                I            DR. MAYER:  Fine.  I would love to have some comment.

                2            I had assumed because it was being dealt with on

                3  the 8th

                4            DR, HINMAli:  Just to set the background, all the

                5  kidney documents did not arrive here until Tuesday which is

                6  why it is being dealt with on the 8tho'

                7            But Ohio in January of 1971 established a planning

                8  group on renal disease that is statewide.  It includes

                9  representatives from Cleveland as well as the major cities in

              10  the new merged area.

              11             They have had adult type kidney doctors, and they are

              12  appointing, either have or will be appointing,.pediatric
              13' type doctors as well.  And they are starting an organ sharing

              14  program within the various centers that will be in the State of

              15  Ohio.

              16             There are three applications in for reveiw at the

              17  present time.    One is to support a pediatric neplirology

              18  program.  That lost its pediatric nephrologist, and it is

              19  basically geared around acquisition of said pediatric

              20  neplirologist and funding him.

              21             The other two are organ procurement and transplant

              22  expansion  programs, one for Toledo and one for Columbus.
              23  Those two  organ procurement programs have had very critical
              241 technical  review.  Interestingly enough, one of them, the
  ,ce deal Reporters,  Inc.
              25  investigators took  into account    at least-thd P,14P did





                                                                              157


                I  and the applicantion as submitted has incorporated the critical

                2  review, the things that needed to be straightened out.

                3            The other does not.  But it does begin to address

                4  theissues of dialysis and organ procurement throughout the

                5  State as a whole.

                6            DR. 14AYER:  It does, you say?

                7            DR. HINMAN:  It does begin to, yes, sir.

                8            DR. YIAYER:  Including the.troops in Cleveland?

                9            DR. IiINI@@li: A little bit.  They are still pretty

               10  independent in Cleveland.

               11            This overall pl anning group has the sanction of the

               12  Governor's office.  He in turn delegated to the Commissioner

               13  of Health, Dr. Cashnan, to pull the committee together.  And

               14  it appears as if there would be some State legislation sought

               15 by this group.  And they are beginning to talk together.

               16            DR. 14AYER:  Other comments


               17            (No response.)

               18            Is everybody clear on the recommendations?  Staff

               19 clear?


               20            All those in favor say, "Aye."

               21            (Chorus of ayes.)

               22            Opposed?

               23            (No response.)

               24            I would recommend to you that it might be worth takinc

  @c  eal Reporters,  Inc.
               25 10   minutes tonight to read through those pages of 27 through 34




                                                                               15 8



                I  in the yellow sheets of the millikan-Everist comments about

                2  the situation that exists there.

                3           DR. SCHERLIS: Pertinent to that, who  is  now  head  of

                4 their RAG? Is it the physician Dr.  Hudson  who  was  mentioned

                5 or who is his latest successor?

                6           DR. MAYER:  No.  Brain Bradford who is evidently

                7 a physician in Toledo who I gather from their comments and

                8 other comments of staff is showing some fairly dynamic

                9 leadership to it.  In fact, the comment was made he knew

              10  more about what was happening than the  coordinator  which  was

              11  an interesting comment.

              12            DR. SCHERLIS:  One  other  comment.  Suppose  elsewhere

              13  in Ohio  aregional program comes in for  funding.  Is  there  any

              14  potential for a technical review group or that  group  charged.

              15  with "regi.onalization" saying that there has to be  an  entire

              16!Qhio renal program  and not a particulated one?

              17            DR. HIN@IP.N:  You mean as far as the statewide corrlmitte@.


              18 that is

              19            DR. 14AYER:  No, as far as RMP is concerned.

              20            DR.HIIII,@N:  The local ICIP or R:,IPI.3?

              21            As far as the local PL@IP is concerned, they have  been

              22  an  active supporter of this Ohio Renal Disease Planning

              23  C:)mmittee as I believe is its formal name.

              24            Technically speaking, they could address themselves

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              25  only to the areas that are in the map shown as being the Ohio




                                                                                 159



                   PIIP.  I would assume in looking at the guidelines, the blue

                2  sheets that were discussed for a while this morning and in

                3  what I am hopeful wi 11 be further issuances coming  from  here,

                4  they will understand that the whole area needs to be looked

                5  at and not just their part of the State.-

                6            DR. SCHERLIS: I hope this is the message -that -  this

                7  committee can help implement.    And that is that even if

                8  technical review is satisfactory, if all of these areas come

                9  up with nice technical reviews, I would  assume  looking  at.the

               10  total national program, we would want to have evidence that

                   this is an integrated program.  And I think this should be

               12  noted.

               1 3           DR. HINT,@l:  The Ohio Valley IU.IP out of Cincinnati

               14  also has some kidney areas of concern.   And we  are  attempting

               15  to get into this total planning process   as well.

               16            DR. SCHEPLIS:  04L course, you  are in a very fortunate

               17  position in that you either do or do not recommend funding.

               18  And you wouldn't have to be anything more than clear in your

               19  direction as far as regionalization is concerned, particularly

               20  4 f yz)u are talking about a n--tional network. Is that clear?

               21            DR..HIN@IAN:  I would hope to be able to be specific,

               22  yes,  sir.


               23            DR. MAYER:  Sister Ann.

               24            SISTER ANN JOSEPHINE:  Has Western Reserve been

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               25 brought into these plans?




                                                                            160



                            DR. HINMALI: The Cleveland Clinic is involved,  but

                2 I just don't recall about Case Western Reserve, sister.

                3           DR. MARGULIES: The Northeast Ohio Program  is  very

                4 closely tied in with Western Reserve.  That is the most

                5 intimate part of their educational base.

                6           When we were attempting to get a total Ohio program,
                7 they were one of the principal actors in the'discussion.

                8 But their area of concern involved in regionalization is

                9 not East Ohio centered around Cleveland.

              10            DR. HINI@I: The kidney area  specifically,  though,

              11  there is already some organ sharing going on between Cleveland
              121 and some of the other cities.  Whether it is only from the
              13  clinic or V@iestern Reserve, too, I  just don't know the

              14  specifics.  But I think both- are involved.

              15            DR. MARGULIES:  I should tell you that the system

              16  they are using for coordinating things in Cleveland is not the

              17  same system they used for handling the poling booths.

              18            (Laughter.)

              19            DR. MAYER:  Yes, @e.

              20            MR. VAII WINKLE: The kidney committee, I would  say

              21  the head of the P14Ps in the State in terms of taking a look

              22  at the total picture and true regionalization, they have

              23  representatives from the Cincinnati area, the Toledo area,

              24  the Cleveland area, the Columbus are.  They are fully

  kc   Ial R6porters,  Inc.
              25  represented throughout the State on this committee.  And that




                                                                              161


                I also becomes their technical review body for any proposal

                2 that comes in to any RMP within the State -- representatives,

                3 you know, from that State committee.

                4           DR. M7,.YER: on renal disease.

                5           MR. V@l WINKLE:  Renal disease only.

                6           DR. 14AYER: O.K., I would like to move on now  to


                7  Northeast Ohio.

                8           We will need to give some thoughts to the degree to

                9  which we feel comfortable about rating or nonrating  of  this

              .10  proposal. I am in the comparison of apples and  oranges  kind

              11  of issue myself which was part of my dilemma on it.  And as I

              12  go through it, I am at the one, two, three end of the spectrum

              13  relative to this.

              14            But I would have to say given the  circumstances,

              15 I don't know how they could be at other than the  one,  two,

              16 three edge of the spectrum in terms of tkying to  develop  a

              17  new @IP.  So the question is do we want to rate  it and what

              18  are the potential implications of that.

              19            Lorraine, any-comments on it?

              20            MRS. KYTTLE:  No, sir.
              21            DP,. SPELL'L@'i:  I don't think I could rate it if it

              22  is going to be commensurate with the decision to fund it.

              23  I don't see how to translate into this.  So  I  just.couldn't

              24  rate it,

  kc   al Repotters,  Inc.
              25            MR. CHAMBLISS:  May I comment there?








                            DR. 14AYER;  Yes.

                2           MR. CHAMBLISS: You asked what are the  implications

                3  of rating, and you had suggested some numbers.  Whereas I

                4  would not suggest numbers, I would say whatever rating this

                5  committee may.place on that region. would certainly give it

                6 some indication as to where it stands. It would  give  it  some

                7 water line as to where it stands as a region-based on the

                8 action of this committee.

                9           MR. HILTON:  Are we talking about rating the

              .10 internal structures now, the internal coordinator and internal

              11  advisory committee, as opposed to region?

              .12           DR. MAYER:  Well, I guess the question of the

              13  committee is do you want to rate it or not.

              14            DR. SPELT24AN:  Let's have a motion.

              15            DR. SCHERLIS:  Again, I am in a dilemma in that I

              1.6 don't see why we should rate it.  We are rating all regions on

              17  the basis of a lot of extenuating circumstances, some more

              18  extenuating than others.

              19            I would think that the numbers that we come up with,

              20  and I assume you do as chairman misuse your prerogative in

              21  telling us how you rated it.

              22            DR. MAYER: I am sorry about  that.  Like  Mr.  Nixon,

              23  I occasionally forget.

              24            DR. SCliERLIS: I would think we should rate  it  just

  .@c  al Reportefs, Inc.
              25  to make matters clear.







                          DR. MAYER:  All right, fine.

               2          Before we do thate I had promised Mr. Iciiinowski

               3  we would coment briefly about the rating sheets before we

               4 did Oregon, and then I flunked again.

               5          Would you care to comment?

               6          Lee, you have another conunent?

               7          MR. VIU4 WINKLE:  I think we are rating something that

               8  doesn't exist, sir.  This new organization that you are taking

               9  a look at is not even legal until September 1.  So are you now

             10  rating the two old region@?

             11           DR. SCIILERIS:  Then we are funding a non-existent

             12  organization.

             13           MR. VAN WINKLE:  That is an application for

             14  September 1.

             15           DR. MAYER:  Subject to.

             16           DR. SCIILERIS:  I think we hve to view the combination

             17 of the two and come up with some evaluating system.  We

             18  reach the evaluation by the level of funding that we gave it.

             19  I assume there is something objective behind that.'

             20           DR. 14AYER:  Comments on the rating systp-m.

             21           MR. ICHINOWSKI:  I have a couple of notes I would

             22  like to pass on to you which could help us as you do the

             23  scoring and some problems that we had with the rating sheets
             24  that we received from the review committee last time.

  ce  -,,,I R6portefs,  Inc.
             25           The key to remember, of course, is the one to five




                                                                             16 4



               I rating. That second column with  the  numbers  running  down  it

               2 is the weights. And regardless  of  whether  a  criterion  has
               3  15 points, the scoring still goes from one to five.  We did

               4  get them running up to 10 and 15.

               5             We would request that each criterion do receive a

               6  score because if you leave one of the criterion blank, that

               7  negates the weight.  And this causes difficulty in calculation.

               8             We also ask that you do not score, even if the

               9  region is  in-your opinion not worthy of but one, that criterion

               10 as a zero.  Because that also causes us some problems.

               11            With some of the raters last time wishing  for  some

               12 more expansion in terms of identifying a  region  other  than

               13 1, 2i 3, 4, or 5, we notice that some were scoring 2 plus or,

               14 3 minus.  The scoring system has now been expanded to include

               15 1 decimal such that if you want to score a region 3.2 or

               16 4.5, you can do this in each of the  criterion.  But  try  to

               17 stay away from something like 2-1/4 because  then  that  causes

               18 another problem with two decimal places.

               19            MR. PARKS:  Would _you go over again the problem

               20 a zero gives you?  I really didn't get that.
               21            MR.,ICHII;OWSKI: A zero, when we multiply  by  the
               22 weight that criteria has just multiplies out to zero.  I would
               23 suggest if you feel a region should be given a very low
               24 figure for that particular criterion, maybe give it a .1 ratherl

  k,e  at Repoiters, Inc.
               25 than a zero because then, let's say the  criterion  you  select




                                                                               165



                  happens to be number 2, accomplishments and implementation,

                2 which is worth 15 points, by you scoring a 0  on  that  element,

                3 your actual output of that is 0 times 15 or 0.
                4            MR. PARKS:  That is accurat7e.

                5            DR, SCHMIDT:  But we don't want it that way.

                6            MR. ICHINOWSKI: That's accurate in terms  of  maybe

                7  what you want to give, but in terms of then compiling it by

                8 some automated calculation technique we are  using,  it.throws

                9 it out as a reject.

               10            DR. @IARGULIES:  It is really conformity to the

               11 machinery  we are asking.

               12            DR. IDAYER:  No.

               13            DR. I.,'-@RGULIES:  Not quite, but actually it throws

               14 off the total calculation if there is a non-entity  in  there,


               15            DR. I.IAYER:  Dr. liess,

               16            DR. HESS: I have a question. If  I  understood  you

               17 correctly, you want some number of some sort other t:nan  zero

               18  in every one of those boxes, right?

               19            MR. ICHINOWSKI:  That's correct.

               20            DR'* IIES-Q: One of the principles of rating is  that

               21 you try not to halo, and you try to be as specific  as  you  can

               22 on every point. If you don't have data upon which  to  base  a

               23 judgment, you are better off not making any judgment.

               24            DR. 14AYER: I thought we arrived at we  would  circle

  kc   at Reporters,  Inc.
               25 those.'






                             MR. ICHINOWSKI: what we have done  in  the  past  is

                2  we have circled those to indicate that the reviewer had

                3  some concern or no data regarding his rating.

                4            DR. HESS: For example,  regarding  Ohio,  there  are

                5  many of these categories we essentially have no information on.

                6            MR. ICIIINOIISKI:  That is a tough region.

                7            DR. HESS:   It seems to me it is very  unfair  and

                8  illegal to make judgments on the basis of  no  data.  We  have

                9  data on certain of those categories, but others we have

               10  nothing.

               11            DR. @IAYER:  Joe, I suggest you circle them and say

               12  that thelprimary reviewer didn't provide you the information.

               13,           DR. WHITE:  What if we should happen to --ay we cannot

               14  rate this,> Does this make the machine angry at  one  of  us

               15            (Laughter.)

               16            DR. ICHINOVISKI:  If you do not rate  the  region, we

               17  have provision for excluding all your dta elements in that

               18  particular region.
               19            DR. SCHERLIS:- If I follow  you  correctly,  then,

               20  if we exclude some, you are going to exclude it all?
               21            MR. ICHINOIISKI: Or else try to come  up  with  some
               22  provision for filling in the blanks that seems reasonable.
               23            DR. MAYER:  The issue is, Leonard, your opinion is
               24  probably better than his about it even though you feel

  ke   ra I Reporters,  Inc.
               25  uncomfortable with it.



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                                                                              0
                             DR. SCHERLIS: But in reality, if you  get  down  t

                2  what we really do is we put down these numbers after we have
                3  such a forceful, lucid presentation as we just had by our
                4  chairman.  Vle attempt to really extrapolate what he is thinking

                5  in terms of numerical value.  And in case we don't follow the

                6  directions, he lets-us know what his numbers are.

                7            (Laughter.)

                8            DR. MAYER:  In advance.

                9            DR. SCHERLIS:  It proves very helpful.

               10            DR. 14AYER:  other comments?

               11            (No response.)
               12            Has everyone who intends to rate the  Ohio  Region

               13.  rated the Ohio Region?

               14            (Laughter.)

               15            DR. SPELLI.IAN:  Yes.
               1 6           DR. @IAYER: Let's move on to the  Northeast  Ohio.

               17  Sister Ann.
               18            SISTER ANN JOSEPHINE:  I have some of the same
               19  difficulties in providing information on this particular region
                                             i
               20  as Dr. Mayer did.  The one contact I had with the data from
               21  the region was as a member of this committee at which time it
               22  was the decision of the group that rather than have three
               23  very weak programs, there would be advantage in making a
               24  reco@, ndation that there be consolidation in      development

  C,   ,al Reporters,  Inc.
               25  of one strong program.




                                                                               16 8



                             However, as Dr. Mayer indicated and the

                2  material that is in your book gives the details of this,

                3 the Northeastern groups  strongly  based  in  Cleveland  decided

                4  not to go along with this recommendation  and  at  the  present

                5  time are submitting a request for funding of an individual

                6  Regional Medical Program,

                7            In assessing this particular   program, one has

                8  to keep in mind that for 17 months, no   coordinator was
                9  present during which time there was not an entire lack of

               10  leadership, however the leadership was shared by many people.

               11  And as a result, the total effort was not coordinated.

               12            More recently#, Dr. Gibbons has been brought i n   as

               13
                   the coordinator of the program. And  in  reading  some  of  the

               14  descriptive material concerning the new coordinator, apparently

               15  he has been in the Cleveland area for many years.  He is Very

               16  well acquainted with the medical community and is able to

               17  work very well with the diversified components there.

                             However, one of the Concerns I personally would have

               19  would be with the fact that-here we a  coordinator  who  is  76

               20  years old. @.nd this is not saying he can't  be  innovative  and

               21  all these things, but certainly the possibility of his availabi
               22  over a period of time doesn't exist at the  same  degree  as  it
               23  might if he were younger.  And besides that, he has no assistant

               24  coordinator to work with him in this program.

  @ce eal  Reportets,  Inc.
               25            And one of the weaknesses of the  program  as  it  was






               1  described by the site visit team chaired by Dr. White in-19,70-

               2  was the fact that core staff at that time  needed  additional

               3  development.  I think the situation still exists.  And I

               4  think that in this particular area of'responsibility of a

               5  coordinator in the absence of adequate core stafff we are

               6  probably going to encounter a great many problems.

               7            The operational projects, four in number, are

               8  in no way related to the objectives that are stated  for  the

               9  region.  This was true in 1970 and apparently it hasn't   been

              I 0 changed in the intervening time.

                            In 1970, concern was expressed concerning the

              12  composition of RAG.  I believe some changes were made.  Addition

              13  "consumer representatives" were added to the group.  Ho%.7ever

              14
                  there is strong domination by the executive committee  which

              15  originates from the board of trustees. And in  reading  over

              16  the material provided, I would get the impression that RAG

              17  simply passes judgments on the kinds of recommendations  that

              18  the executive committee and the board choose to submit to RAG.

              19            I.believe, Mr. Parks, would you want to give  some     I

              20  of your other impressions?

              21            DR. @IAYER: Mr. Parks is secondary reviewer on  the

              22  project.

              23            MR. PARKS:  Sister, I concur largely in what you

              24  have said.  As a matter of fact, totally.  And, again, I think

  ,ce   I R@portefs,  Inc.
              25  the predicament here highlights a situation which is incapable




                                                                                170



                I  of evaluation.

                2            The predicament does not lend  itself  certainly  to
                3  any of the factors w hich we have on our evaluation sheets.

                4  We are faced with a situation where we have  a  new  coordinator

                5  who did not participate, I understand, in  development  of  this

                6  particular application that we have here and a rather sparkling

                7  record 'of failure in this case.

                8            I know of no other way to present it accurately.

                9            My basic inclination is that assuming  it  would  be

               10  an appropriate remedy for this committee,  I  would  recommend

               11  that this program be shut down.

               12            The situation is tempered somewhat by some information

               13  that wa@ delivered to us today and by some  previous  action  of

               14  the National Advisory Council which would appear to pre-empt

               15  the action by this particular committee.  And that is contained,

               16  I believe  in the papers which you have.  It is a letter

               17  dated February 10, 1972, from Dr. 14argulies  which  transmits

               18  to Dr. Glover the action of the  National  Advisory  Committee

               19  which is to the effect that the program be retained at its

               20  present level of funding,

               21            And so it would  seem, then, that anything  that  we

               22  might have to recommend to  this committee with respect to eithe-@

               23  continued funding or level  of funding would be  superfluous  at

               24  this time.

  kce   I Reporters,  Inc.
               25            It does, I think, relate to the larger question of th




                                                                               J.71



                I  role of this committee and especially in a situation where

                2  the National Advisory Council has spoken on the matter previous'

                3            There was, I think, in this case as in the other

                4  Ohio situation a site visit conducted by some members  of  the

                5  Council.

                6            There are-some items about which we might particularly

                7  with respect to the Regional Advisory Group, its  make-up  and

                8  composition, the distribution and participation that is

                9  effective participation of minority persons, the participation

              10   of minorities on the staff, the non-application  of  priorities

              11   which are established to program activities.

              12             For example, they indicate that their  top  priority

              13   is meet'ng some of the needs of the people in the urban zzreas,

              14   And certainly running down those four priorities, I  find  none
              15   of the op, erational effort directed to  this.  I  find  certainly
              1.6  again with the exception of the Urban League director, I

              17   don't find among the members of the Regional Advisory Group

              18   or the trustees the kind of participation from among the

              19   consumer element that you would expect to find in  a  situation

              20   like this based in an urban setting such as Cleveland.
              211            I think there is something to be said for having
              22   engaged a coordinator who has the historical qualifications

              23   that Dr. Glover presents.  Among the papers which were

              24   presented to us was a statement indicating that he has trained

  @ce   I Reporters,  Inc.
              25   the majority of the practitioners within,this  region's  scope





                                                                              172


                I  of activity.  And it is largely through his standing within

                2  the medical profession-and his personal.acquaintance with

                3  the principal actors that he is able to bring together and

                4 perhaps to effectuate some change.

                5           The-papers that were handed over just momentarily

                6 I think Sister has those -- may throw some light on it  as  to

                7 prospective activity.  But if what we are rating covers
                8 the period in the past, I would say that this program is

                9 questionable and based on its past performance, I would say

              10  that'- it was of doubtful prognosis for the future.

              11            Nonetheless, we are advised, I am advised?  that  the

               -12 new director, despite his yearst and possibly because  of  it,

              13  has, I.guess accentuated change and is currently developing and

              14  restructuring this particular program.

              15            But for those qualifications, I would say,  first  of

              16  all, there is a very real question as to whether this business

              17  is appropriately before this  committee.

              18            The second thing is if it is an appropriate  rertedy

              19  for this committee to recommend, I would be  for  recommending

              20  the money for this program be withdrawn.

              21            DR. IIAYER:  Could we deal with the question that

              22  is being raised?  Because I have a little trouble with

              23  substantial inconsistency of the letter of February 10, Harold,

              24  in which it implies that @ National Advisorv Council

  ce    I Repotters,  Inc.
              25  recommended at this time, presumably in the  February  Council,




                                                                               173



                  a continuation of supprt for one year at a basis not to

               2  exceed the existing level funding.  And then in the concluding

               3  paragraph, it says, change in review cycle will start  date

               4
                  for Northeast Ohio program from June @o September @,  1972.

               5  Therefore, the present grant period for Northeast Ohio will

               6  extend through August 3le 1972.

               7             And presumably, this application deals with  that
               8  period after August 31, 1912. And yet presumably  there  is

               9  some kind of commitment for funding in the region through  to

               10 what -- February of 1973?
                             I understand the issue you are raising because  I  can'4-

               12 see it.

               13            DR. DIARGULIES:  What @-ppened earlier when we reached

               14 the same conclusion you did about the program  which  is  that.-

               15 both Northwest Ohio and Northeast Ohio  were  of  such  doubtful   I

               1.6 quality that there was serious consideration about whether  tney@
               171 should be continued at all, we did  put  considerable  pressure
               18 on them to make some basic alterations.  We, in fact, limited

               19 their funding during that period of time  to  six  months  and
               20 then gave them an extension of six months  to  see  how  effectively

               21 they could work out their plans.
               22            And when they reached a tentative agreement which
               23 required the Council to act on whether or not they should  conti.-,-,

               24 the decision was made they should have  funding  for  one  year.

  ce    I Reporters, Inc.
               25            What you are addressing would affect their activities
                 I




                                                                               174



                1  thereafter.  And so if you were to make a recommendation here

                2  that this program should no longer be continued, it would be

                3  a matter of phasing out their activities with existing funds

                4  and then closing it down.

                5           MR. PARKS:  When would be the date that their

                6  current funding would terminate?

                7           DR. MARGULIES: Their  current  funding  under  this

                8  one-year extension -- I will have to as k for some help on

                9  that.


              10            MRS. KYTTLE:  August 31.

              11            DR. I.IARGULIES: August 31 of this year  as,far  as
              121 I know,  172.
              13            DR. @IAYER:  Except there is an implied commitment by

              14  Council until Februaryt at least one year from February 10,

              15  in your letter.

              16            DR. MARGULIES:  Well, I am sorry because the letter

              17  was confusing.  That referred to the six months and then

              18  six-month extension so that so far as I know they are funded

              19  only through August 31 of 172.

              20            DR. SPELLMAN: Was one  of  the  clear  alternatives

              21  merger or abandonment, so to speak?

              22            DR. MARGULIES:  No.  We did not require them to merge.

              23  What we did was lay out to all three programs their deficiencies

              24  and recommend they give  merger  serious  consideration.  And

  @ce  fal Reporters,  Inc.
              25  that's why we had members of the Council go out to see what





                                                                               175



                  progress they had made.

                2            The efforts to consolidate were partially effective.

                3 So you see two programs instead of three.  But  we  still  have

                4 the problem of Cleveland and the rest of Ohio.  And the

                5 viability of the program is one to be judged at the present

                6 time.

                7            SISTER ANN JOSEPHINE': This morning when I  said  we

                8 have to be sure we ask the right questions, I was thinking

                9 in terms of this report.  And I personally don't feel that the

               10 question is at what level shall we fund them,but  I  think  the
               11 question, is should we fund this program.  Should  we  continue

               12 to fund:this program?

               1 3           DR. MAYER:  Comment, Phil?

               14            DR. WHITE:  I don't understand this concern in

               15 reading this. Some of the comments by Drs. Millikan and

               16 Everist suggest that in spite of his age, Dr. Glover seems to

               17 have some leadership qualities.  What has happened since that

               18 time?  Has he made any move?

               19            Is Dr. Hudson still a thorn in their side?

               20 Has there been no progress  at all since that visit by Dr.

               21 Millikan and Dr. Everist, or has there been?

               22            DR. MARGULIES:  Do you want to comment on this?

               ?3            DR. MAYER:  Mr. Ashby, comment?

               24            MR. ASHBY:  Actually, Dr. Glover is able to contain

  4,e eal RLpottefs, Inc.
               25 even Dr. Hudson.  He does a good job of that.




                                                                                       lib


                  I             And, yes, he has been very busy..  The program staff,
                  2  at this time, morale is much higher.  They seem to be working
                  3  harder, although it is just.observation.  Everyone that has
                  4  met him seems to be impressed.  Even though he is 76, he is
                  5  a young 76.  He  realizes  his  age  is  a  limiting  factor  as  far
                  6  as being able to  be  around  in  that  program  for  a  long  period

                  7  of time,
                  8             He impresses me as a    mover, a iid I don't  believe   he

                  9  would have taken the position     at all if he hadn't    thought   he

                10   could do something with the program.  He was one of the

                11   biggesticritics the program had prior to his acceptance as

                12   coordinator.

                13,             DR.   WHITE:  I gather Dr. Robbins

                14              DR.   MAYER:  Phil, we couldn't hear you.
                15              DR.  IIHITE:  I was asking if Dr. Robbins, the dean

                16   of the s   ool, was in   favor of PI,IP.
                17              DR. I.IAYER:  That to me is   one of the great unknowns.
                18   Fred Robbins, in spite of his research background and his
                19   Nobel-laureacy is really committed to community health action
                20   efforts.  And yet here sat that RMP all this time without
                21   movement.  And I can't put those two facts together in my
                22   mind.  If anybody can help me with that out of staff or

                23   elsewhere

                24              DR.   ELLIS:  I can.

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                25              DR. MAYER:  All right, Effie.





                                                                              177


                             DR. ELLIS: His philosophy was a little  bit  out  of
               2   line  with that of the rest of the people at the  time.  And  I
               3   think  the Midwest is pretty-conservative.  And  this  accounts

               4
                   probably for the fact that it would take a little while to get

               5
                   the  show on the  road.

               6
                             DR. MARGULIES:  Fred has been  very deeply  involved

               7
                   in the efforts to rebuild this program.   When we first  tried

               8
                   to have a merger of all three, he was one of the leading
               9   voices for a true merger.
               10            The problem, on the other hand, getting back to
               11  Northeast and the question of why didn't it got  Bill,  so  far
               12  as I could tell, it was the inability of the people in

               ]3z
                   Cleveland to resolve their own internal differences.  It is the
               14          II
                   old  issue of Western Reserve and the Academy of  Medicine  and

               15
                   the  local politics. And about the time he would  make a

               16
                   move an one direction, he would run into Charlie  Hudson coming

               17  from the.other direction.  And he has not really  been able  to

               18  overcome some of the resistance.

               1 9           I think if he -had had a free hand and if there  had

               20  been a coordinator --  You may remember when this  program  was

               21
                   first developed, the coordinator was a fellow named Barry

               22  Decker who was a very vigorous, imaginative,  hard-working  guy

               23  who got the program through the p2anning stage and promptly

               24  was recruited away.  And they then were unable to get a
  @ce  "I I Repotters,  Inc.
               25  coordinator.  And I think the main reason they couldn't get one,




                                                                                     17 8




                    and this is the real stalling point is because they couldn't

                  2 reach a resolution between the vying medical-political forces

                  3 within the Cleveland area.  They would got somebody, and if

                  4 it was All right  with  Western  Reserve,  it  wasn't  all  right

                  5 with the  Academy.  And  sometimes  they  would  say,  "Maybe  we

                  6 better go out of state to get somebody who is neutral."  And

                  7 they  were  really  bung up  on  their.own  internal   differences

                  8 while  Fred  was  trying to get something  reasonable accomplished.

                  9            fie is  still actively  interested.  He   still   gives

                10  strong  support  to  the new cco--dinator.  I don't know that they

                11  have resolved those problems.

                12             SISTER ANN  JOSEPHINE:  The question that arises

                13- -in my ml d is would  it be and it would seem to me that it might

                14  well be to the interest of  the  total  State  to  take  a  stand

                15  that might give a little more encouragement to this merger.

                16             DR. 14ARGULIES:  I quite agree.  What we have said

                17  is that we acce  ted  the  present  arrangement  as  a  tentative
                                    p

                18  one, but we insisted they continue to work toward a final

                19  resolution of a total State system.  But that is sort of good

                20  advice.  I don't know how    strongly it is accepted or how much

                21  meaning-it has.  They are    meeting together.  They will talk

                22  with one another more and   more, but it is not quite what you are

                23  talking about.

                24             DR. @MYER:  Yes,, Leonard.

  @ce   al Repotters, Inc.
                25             DR. SCHERLIS:  Do I read    correctly the printout their







                   budget essentially is divided between tl-le.four, the  hospital

                2 librarian, coronary care  unit  training  strep  culture,  and

                3  strong reh,@?  Is this the total progr'@im?

                4            SISTER ANN JOSEPHINE:  It is really not.  It is a

                5  very difficult program.  They call it program.

                6            DR. SCHERLIS:  That comes to something like


                7  $800-some thousand.

                8            SISTER ANN JOSEPHINE: Actually, I  think  we  are

                9  describing a planning component and calling it an operational

               -10 program.

               11            DR. 14PRGULIES: We have had  repeatedly  from  that

               12  program whenever we have leaned on  them  hard,  particularly

               13  about the coordinator, the co--plaint that there is  so  much

               14  national instability in the Regional,Medical  Program  that  it

               16  is impossible to get a coordinator.  And we keep telling them

               16  it is like arguing that you lost the ball game  because  it

               17  rained. The other team is in  the  same  rain.  Other  programs

               18  have developed, have had strong coordinators, have replaced

               19  them and got good people, and they haven't been able to.

               20  But they have used this as a kind of a defense  for  not  doing
               211 anything.
               22            Vlhen you look at how long that program has  been

               23  without a coordinator, it has been ever since  they  became

               24  operational up to the present time when they  have  gotten  Dr.

  kce   I Rdpofters,  Inc.
               25  Glover in.  And that has only been within a matter.6f a few

                 I




                                                                          180



               I  months.  I think he came on board in January.

               2            DR.I,.LAYER: Yes, Joe,

               3            DR. HESS:  It seems to me we have to look, if we

               4 accept Mr, Parks'  and  Sister's

               5            DR. MAYER:  Could you use the mike?  We really

               6  can't hear you.

               7            DR. HESS:  If we accept Mr. Parks' and Sisterl's

               8  feeling perhaps the thing to do might be to recommend the

               9  phaseout of this program, then we have to look at what happens

              10  if that actually is taken.

              11            I think we would be in a better position or at least

              12  I would feel more comfortable about being in favor of that if

              13  the Ohio program were in a more stable state itself. But I am

              14  just wondering if that wouldn't add an additional burden to

              15  two regions that are already tryin@ to merge and a coordinator i

              16  that is only there for another month or two.  And how much can

              17  it take?  What are we going to do to MIP in that whole State

              18  if we do this all at once?

              19            Maybe one way out of this dilemma is perhaps delay

              20  this for a year and give the Ohio RMP a chance to see what it

              21  is going to be able to do and then take another look at it.

              22  And maybe merger would be appropriate at that time.

              23            But I must say I am worried about wiping this one

              24  out and saying merge with Ohio right now in their current state

  ce   I Repoftefs,  Inc.
              25  of flux.








                             DR. MAYER:  Sister Ann.

                2            SISTER ANN JOSEPHINE:  I wonder if in line with this

                3 February 10 letter which could well give us a position that we

                4 could continue the funding until February of  173  which  would

                5 be nine months and say by this time, you know,  we  would  hope

                6 you would be able to work out these  differences,  that  would

                7 provide  that leeway in keeping with something that we made

                8 some kind of a commitment to.

                9            DR. MAYER:  Well, what would we expect?  I  guess  I

              10  need to have some feel in term,- of the new cycle,  what  that

              11  would mean.  Presumably, that would mean that would have to be
              12  reviewe4l in January which says that whatever  new  application

              13@ would have to be inhouse when?

              14             1 am trying to get a,feel for what kind of  time  is

              1 5 that.

              16            @DR. 14ARGULIES:  November.

                             MRS. KYTTLE:  I think we ought to look at ohio's
              17

              18 schedule more than this region's  schedule.  If  we  want  them
              19  to think about effecting a merger within a  certain  period  of
                  time, should we not be looking at the place with whom thev
              20

                  will merge rather than this place?
              21

                             DR. MAYER:  I am not sure I was hearing a clear-cut
              22
              23  call for merger. I think what I was  hearing  was  a  clear-cut
              24  call for turning it around or else.  That is v7hat I was hearing.
  ,ce   I R6pofters, Inc.
                             SISTER ANN JOSEPHINE: No. I  think  we  are  moving
              25




                                                                                182



                I  toward merger in this.

                2           Really, it is very difficult to motivate  any  other

                3 way in some cases. I mean,.it is a matter of  really  the  funds

                4  are the'strong point you have.  And as I read all this, it is

                5  not just an arbitrary decision.  It is really in the best

                6  interests of the total program for the people.

                7           MR. PARKS:  With respect to merger, if,you allow this

                8  program to survive, I think the question of merger is an

                9  appropriate local decision.  I think it is an especially

              10 important one. I think we should be careful  not  to  get  into

              11  a posture where we begin to dictate what ultimately ought to be
                          @decision because we also would be the ones who will
              12  a local
              13' come al@, ng and evaluate them.  And we may have forced them into
              14  an unnatural situation.

                            And I would certainly hope  that even though that  may
              15
              16  be something of a tactical guess as  the appropriate  direction,
              17  I certainly would dissent from any decision that would indicate'
              18  to them that we expected or would expect as a factor of
              ig  evaluation to have these programs merged into a single  unit..

                            I think more important that we have an effective
              20
              21  unit that meets with your broad national priorities. And as

                  long as it is operational and if you can ascertain that it is
              22
              23  moving effectively in that direction, if you can find a mechanis-
              24  to close the book on a bad chapter and rate that  chapter  for
  .ce   I  Reporters,  Inc. precisely what it is and then the next time you take a  look  at
              25







                   it, measure it from this time forward, I am  not  so  sure  1

                 2 would want to be in a position of this  place  and  with  the

                 3 information that we have indicating  to  them  that  they  must

                 4 merge or else.

                 5            I really don't have the  information  to  make  that

                 6 decision.


                 7            SISTER ANN JOSEPIIINE:  I agree.

                 8            DR. MAYER:  Let me see.  To me, it seems like we have

                 9  roughly three options given the kind of tenor of the discussion.

               10             One option is that we say effective August 31, they

               11  are out.of business.  And they can come back in and reapply

               12  for a ne, w RZIP if they want to do that in some  form  at  some

               13.  future date.   That's one step we can take.

               14             The second step we can take is extend them to the

               151 Februarylperiod and say that by November you must have a

               16  program in here developed for review or  you  will  be  out  of

               17  business effective February 28.

               18             Or, thirdly, we could say, all right, we are extending

               19  them at some level from-,now, from August of  this  year,  to

               20  August or September 1 of next year with  the  same  kinds  of

                   constraints on it.
               21

                              Now, those to me seem to be the three options.
               22

               23             SISTER ANN JOSEPIIII,4E: And if we did No.  2,  what

                   would be our expectations at the end of that time?
               24
  ice   I Reporters, Inc.     DR. MAYER:   That is up to us, the committee.    And we
               25





                                                                             .L 0 -t




               1  need to have those laid out more precisely.

               2             Yes, Joe.
               3             DR. HESS:  In connection with your third option,
               4  might we consider recommending what in essence would be
               5  reversion to a kind of a planning phase?  Phase out many of
               6  these activities and ask them to take a good, hard look and
               7  come in a year  from now, fund them for sort-of a planning year,

               8  come back in with a better plan which reflects some very
               9  serious rethinking of where they are going to go and how they
               -10  are going to get there.  And this would keep them in phase with
               11  the Ohio, and that would provide an opportunity for them to
               12  look at this question of merger as well as to look at the
               13  strengths they have to pull the program together.

               14            Is that possible?
               15            DR. @IAYER:  Sister Ann, comment?
               16            SISTER ANN JOSEPHINE:  Is Ohio in a planning stage

                   now, planning phase?
               17

                             DR.MARGULIES:  No.
               19            SISTER ANN JOSEPIIIINE:  It is operational?
               20            DR. IIAYER:  Except that the recommendation we made
                   vis-a-vis the new Ohio R.MP was most of the dollars in the core
               21
               22  staff to support that planning group and evaluation grouD that
               23  they are proposing for the two combined regions with very
               24  little money in terms of operation.  The money that we
  %ce  rat R6portefs,  Inc. suggested was roughly two to one, three to one, in terms of
               25




                                                                         185


               I  staff as opposed to projects which is the reverse of the

               2 usual situation.

               3           So in that sense, we have moved them in that

               4  direction.

               5           SISTER ANN JOSEPHINE:  Then, what Dr. Hess is

               6 suggesting would enable us at the end of the year to

               7 evaluate the region'-s capability of planning and ability to

               8 become operational or not.  Is that what you are saying?

               9           DR. HESS:  Right.  Cut them back, phase out the

              10 project funding or reduce it substantially.

              11           SISTER ANN JOSEPHINE:  And it might even be that

              12 during this period of time, they could begin to look toward

              13 maybe working more closely with the other Regional Medical

              14 Program in the State.  '4aybe that is the way they can take thei

              15 first step.  Maybe it isn't the most desirable way to go.

              16           And then if their planning stage, if at the end of the'

              17 planning period, the group felt that they were ready for

              18 operational funds, then we could move in this direction.

              19           Is it just one year for planning?

              20           DR.' @IARGULIES:  Technically, we would not put them

              21 into the planning stage because that has too many legal

              22 complications.  Functionally, in a planning stage, which works

              23 out the same way.

              24           The only cor,-L-ient I would like to make regardless of

  ce   I Reporters,  Inc.
              25 your decision is I think this extraordinary attention to the




                                                                             186



                1  prog ram is well deserved.  If they get through the present

                2 period of pressure and emerge as Northeast, Ohio feeling

                3 that they can now feel as though  they are on sound ground, they

                4 will be making a very bad mistake, ana so  will  we.  Because

                5 what has come out of it is anything but satisfactory up to the

                6 present time.

                7           But we do feel the potentials  are there.  But potentia

                8 aren't enough.

                9           DR. SPELLI.IAN: Which means at the end of that  year

              10  they would if they had not merged or had not  made  progress,

              11  you would have to phase them out.  That would have to be Clear.

              12  otherwise, you would just be repeating the same.

              13            DR. MARGULIES:  That's right.

              14            SISTER ANN JOSEPHINE:  And the success that has been

              15 subscribed for this program rather'recently is  all  bound  up

              16 with one particular person, not a program.

              17            DR. MAYER: Am I clear that their  current  level  of

              18  direct cost funding is in fact $690,000'.> I am looking on,  I

              19  guess it is pink.  I am not sure whether it is pink or salmon,

              20  but it has an asterisk and says "Does not include 24-month

              21  extension for 01 year of $2,376,000."  I don't understand it.

              22            What level of funding are they currently at?

              23            Let me make a suggestion-in terms of staff.  At least

                  what I need or what I needed when I reviewed programs  is  to
              24

  ce    I Reporters,  Inc.
              25  have a fix on what the current annualized, most up-to-date




                                                                              187


               I  operating costs are of the program as it is then functioning.

               2            Now, maybe we' have got in here that data,  but  if

               3 somebody said to me what are  they  currently  functioning  on

               4  an annual rate basis in terms of core staff and in terms of

               5  project -- that is the information we need to have in terms of

               6  where they are.  I don't know where they are.  They are some@.;he

               7  between $2.3 million and $690,000 on an annual basis.  I don't

               8  know where they are.

               9            Ca4 staff help?

              10            MRS. KYTTLE:  We don't have their current expenditure

              11 rate in here because we don-It have  it.  We  get  expenditure

              12 rates 120 days after a program year  is  ended.  And  then  they

              13  are negotiated and audited.  7nd it is quite a while before

              14 the review system gets that information. By  the  time  we  get-

              15 it, the review system has traditionally felt  it  was  so  old

              1.6  that it was not applicable to the year that we are considering.

              17            DR. MAYER:  Let me ask the question a different way.

              18  We must have some idea of  what-their  anticipated  expenditure

              19  is from September 1, 1971, to August 31, 1972,, which  is  when

              20  the thing runs out.  or don't we even have that?

              21            I-IRS. KYTTLE:  Their anticipated expenditure?

                            DR. MAYER: How many dollars have  they  got  to  deal
              22

              23  with?
              24            MRS. KYTTLE:,  You mean their award?

  ce    I Repofters,  Inc.
              25            DR. 14AYER:  Yes.




                                                                              188



                I           @MRS. KYTTLE:  This region had so many extensions

                2 that it had a 24-raonth 01 year. And their 690  is  a  12-month

                3 proration of that 24-month money.

                4           DR. SPELLMAN:  That 831?

                5           MRS. KYTTLE:  lqhere  is Vernon?  Did I say that right,

                6  Vernon?

                7           MR. ASHBY: Not it is  not.  The  $786,187,  they  are

                8 funded now for an 8-month period. I was  trying  to  figure  it

                9 out here.  It is 5 something.  And it was divided by 8 and

               10 multiplied by 12 to give you the figure out here on  the  right-

               11 hand column.

               12           DR. MAYER:  So  the ball park is $786,000, then.  That

               13 is the level they are functioning at.


               14           MR. ASHBY:  Yes.


               1 5          DR. @IAYER:  O.K.


               16           DR. SCHERLIS: May I  have  some  other  clarification

               17 on funding? I-le have used the terms growth and development  and

               18 found that somewhat confusing.

               19           Doctor, looking at the record, would you  give  me  a

               20 guess as to what you would think a reasonable amount of funds

               21 that a region of this size with a core of $540,000  to  allocate I

               22 feasibility studies -- that is somewhat development  and  growth

               23           DR. MAYER: I.don't under-stand the question,  Leonard.

               24           DR. SCHERLIS:   I guess what I am driving at is

  @ce eal  Reporters,  Inc.
               25 looking at their summaries of core, the $539,000 for core




                                                                              189


                I activities, they spent $246,000 for  feasibility  studies  which

                2  core activity in an area that has had so much  difficulty  with

                3  lo oking for programs seems to me an excessive amount of money,

                4  particularly since their entire project support is  less  than

                5  that.

                6            What I am making is obviously the one I  don't  know

                7  how they manage it. :Is there any'reviev7 of RMPS of those

                8  expenditures as they'go on?

                9            SISTER ANN JOSEPIIINE:  I don't have any data.

               10            @IRS. SILSBEE:  As a ramber of SARP, we looked at

               11  the money they v7ere spending for those kinds of things  under

               12  core as being the only hope for this program.  It was small

               13' studies  hat were going on under the core staff.

               14            DR. SCHERLIS:  It must have been a lot of small

               15  studies.

               16            DR. PIAYER:  Dr. Ifinman.

               17            DR. HIN14AN: One of these feasibility grants  was  to

               18  the Youngstown Warren area which is one of  their  regionalized

               19  areas and has developed into a community-based manpower

               20  development Proposal which will be reviewed on  the  21st.  But

               21  the planning group and the concerns of the group seem most

               22  appropriate in Youngstown and Warren. So there  has  been  some

               23  payoff for these dollars.

               24            SISTER ANN JOSEPIIINE:  Were they specific about what

  kce "a[ Peportefs, Inc.
               25  the payoff was?





                                                                              i:j u




                I            DR.  IiINMA14:  Well, I visited with them in one of

                2 their planning sessions, and they had  brought  together  the

                3 people from the three counties in Ohio and the two in

                4 Pennsylvania that were contiguous that are  in  this  medical

                5 trade area -- consumer representatives, medical society

                6 representatives, education representatives -- to sit down and

                7 talk about whether or not they wish to try  to  do  something

                8 together along the model of  either.the  Carnegie  Commission

                9 mental health education center or the  MIP  defined  community-

               10 based manpower d evelopment.

               11            The total dollar investment, I think, was  in  the

               12 neighboxuiwv" w,- $12,000 or $14,000. And it was  basically  in

               18 the salary of i,irs. Baird, the area coordinator, who was

               14 spending, the time and effort in developing this program.

               15            DR. SCHERLIS:  It was $26,000.

               16           'SISTER ANN JOSEPHINE:  One of the strengths of  this
               17 program,, if I were to try to identify a strength, has been the

               18 ability  to get different groups together.  You  know,  without

               19 going into this as a feasibility study.  At least this would be

               20 my feeling.

               21            DR. MAYER: Well, let me go back.  I  think  we  have

               22 got the three possibilities. And then  under  those  three,  we
               23 have to arrive at a level of funding with some principles
               24 hooked to it that people can understand and rationalize.

  %c   at  Reporters,  Inc.
               25            Yes,




                                                                           19 1




                            MR. GARDELL:  I just say the funding, then, is

               2
                  $781,000 we are working with.  we had no Council level, approve,@
               3  level, of record because that was the end of its program period,
               4  And so we were just working on an extension basis.  That was
               5  the level prior to the cut in 171.  And it is the figure we

               6
                  have been working with all along.
               7            DR. 14AYER:  The $781,000 which has roughly $500,000
               8  or $600,000 of core and a couple hundred thousand of  projects.

               9
                            MR; GARDELL:  I don't know what the breakout is.

              10
                  All I know is the total figure.
              11            I also should say to you we don't have any expenditu--O-'
              12  reports from that year. We are still extending  that'71  grant.

                  And it is running 26 months. And you don't get  an  expenditure

              14  report until 120 days afterward.

              15            DR. 14AYER:  Leonard.

              16            DR. SCHEPLIS:  I would suggest that they spend some

              17  of their feasibility funds to learn how to write grants.  1

              18  could make absolutely no sense'out of that document.

              19            What you are telling me about the length of year one,

              20  1 have always looked at year one rather conservatively as

              21  being roughly 12 months, as I understand it.  I don't accept

              22  220 percent year one unless it is clearly stated in the

              23  record.

              24            And to pick up that blue book, I want to congratulate
  %C   al R6porters, Inc.
              25  the two of you who reviewed it for making any sense out of  it.





                                                                               192


                  I find it completely lacking as far as any history or what

                2 went on.  Was I short-sighted when I looked at it or were there

                3 pages that were missing?  Because there was absolutely no
                4 history.  And I tried to figure out h@w they did every   thing

                5 they did in one year.

                6            How they can get this bad a record in one  year  is

                7 something  I could not figure out. It was a  rather  long  year.

                8            DR. 14AYER:  Dr. Schmidt.

                9            DR. SCHMIDT: I don't think it  would  be  appropriate

              10  to close  them down.  And I think what we ought to do is approve

              11  them for a period of tire that would be approximately a year

              12  or whatever it would be to get the end  of  their  time  matching

              13  the end of the time of the Ohio proo-ram, whatever that

              14             DR. MAYER:  That is, I gather, August 30.

              15             DR. SCHMIDT: And they should be  instructed  that  the

              16 options at that point would either be that  they  make  the  case

              17  for an independent Northeast-Regional Medical  Program  or  they

              18  are merged or they will be shut down and that the level of

              19  funding be someplace around $500,000  or  $600,000,  something

              20  that will get them down so that they have  to  start  shutting

              21  down their projects and enter a planning phase and come back

                  up again. And the funds should be limited  to  the  extent  that
              22

              23  this will force this, maybe $500,0_00 or $600,000 to  do  that
              24 @with the instructions stating in effect what we  are  asking  for
  re   I Reporters,  Inc. is a plan for this Regional Medical Program that  we  would  look
              25




                                                                              19 3




                I  at and evaluate.

                2            They have either got it or have to throw in with the

                3 other one  or they have got to quit.  Having the end point

                4 being the  date

                5            DR. MAYER: Which is August 31, 1973, which  is  what

                6 it would be.

                7            DR. SCHMIDT: If there is a sense to  that,  I  would


                8 so move.


                9            DR. SCIIERLIS:  Second.

              10             DR. SP ELL14AN;  This August or next August?

              11             DR. MAYER:  This August there is no way they can

              12  comply with what he is asking.

              13@            DR. MARGULIES:  He is talking about  '73.

              14             DR. MAYER: So what Mac is  talking  about is reconLmenc
              15 ing funding at a level which is kind  of  fuzzy,  and we will
              16  have to sharpen that up, from September  1,  1972,to August 31,
              171 1973, which is one year and does include  12  months,  Leonard,

                  with explicit instructions that at the end of  that  period  of
              18
              19  time, they ought to have inhouse a grant application which either
              20  justifies their continuation as an @IP, as  Northeast  Ohio  or

                  merged or some other effective thing or their funding is going
              21
              22  to be discontinued.
              23             DR. ELLIS:  May I ask a question?

                             DR. MAYER:  Yes, Effie.
              24

  Ice   I  Reportefs,  Inc.
       la                    DR. ELLIS: I want to ask one  question.  I  want  to
              25




                                                                             19 4




                  ask Dr. Margulies do you think if staff works with them more

               2  closely as they are set up, they will improve and their

               3  horizons can broaden?  If you could get a younger person

               4  with newer ideas to work under Dr. Glover if he is  going  to

               5  be there for a few years or more or something like that,

               6  this would be helpful.

               7            It doesn't sound to me as if merger would be possible

               8  that is, a real sound merger -- within the period of  a  year

               9  or even two or three.  Perhaps it would be bette r to say  move

              10  toward that if this seems likely.

              11            But I don't know if they are going to be able to

              12  do too much unless they do have someone kind of really helping

              13  them and monitoring very.closely what they are doing and

              14  suggesting a way.

              15            DR. MARGULIES: Well, so far as  staff  capacity  to

              16  improve the program is concerned, I guess my best response

              17  is God willing. They are there. In  fact,  I  think  probably

              18  staff in that part of the RMP,.DOD, has spent more time on the

              19  Ohio programs than any other. And the major  benefit  has  been

              20  in the other part of it where a merger has occurred.  ?nd in

              21  the process of merger, some real new thinking has gone on.

              22            Staff at the present time, as I indicated,  has  some

              23  hope for the Cleveland end of it doing well.  But I think it

              24  will not do well unless the kind of very specific action which

  @ce  tal  R6porters,  Inc.
              25  you are talking about does come out.    So they don't think that




                                                                                      195


                 I  this  is  just  a  mild gesture; but it  carries  with  it  not  a
                 2  veiled,  but  an   open threat, fish or cut bait.  I don't see any
                 3  other way in which    staff wil-1 have the  backing  to  have  an

                 4  impression on what    goes on.
                 5              14ISS ANDERSON:  Somebody mentioned their relation-
                 6  ship with Pennsylvania.  is that a reality?  Could they

                 7  possibly merge with that group?
                 8              DR. MARGULIES:  No, this was just on the local basis.
                 9              MR. HILTON:  I was just going to ask simply on the
                 10 discussion stage on  this  motion,  I  wondered  if  there  is  a
                 11  possibility or the danger that this action might be interpreted
                 12  by  thoseIon the receiving end as indeed somewhat vindictive
                 13' on the nart of  RI.IPS

                 14             DR. MYER:  Somewhat what?
                 15             MR.  HILTON:  vindictive,    punishment for them for
                 16  not     Because  it seemed there is     no  concept  of  merger.
                 17  The  seed has been planted already even in that February 10
                 18  letter.   It has been  suggested,  and  they  have  heard  that.
                 19  And  they recognize that as a product.  And would this action
                 20  coming when it does not come  off  as  being  a  little  bit  of
                 21  we are punishing you already kind of thing?  And possibly the
                 22  suggestion that Dr. Ellis raises of having somebody work in4q--er-
                 23  nally to bring about change might represent a more meaningful
                 24  alternative than bringing down the guns quite that firmly.

  AC     at Reportefs, Inc.
                 25             1 just raise it as  a  suggestion  in  terms  of  the




                                                                             19 6



                I image of P14PS with regard to the local autonomy  of  these

                2 programs.

                3           DR. SCHERLIS:  I would like that to be made very clear

                4           DR. MAYER: Mac, would you  care  to  sharpen  your

                5 thoughts either in consultation with Sister or how do you want

                6 to arrive at a level of funding or do we  suggest  that  you

                7 might all do that tonight and plug in  that  blank  tomorrow

                8 morning?

                9           DR. SCHMIDT:  Either $500,000  or $600,000.33.

               10           DR. HESS:  To resolve that dilemma, I would like to

               11 make a suggestion.

               12           On page 4 of the  pink sheets here, the summary sheet

               13'          DR. MAYER:  Page  4 of what sheet is  that,  Joe?

               14           DR. HESS:  The summary sheet, table of contents,
               15 14ortheast\ern Ohio anniversary application, page 4 that has the
               16 figures on it, financial summary, if you add up out of the

               17 column "Current Year's Award", one operation year, and I am

               18 assuming that these are 12-month figures, if  you  add  the

               19 $481,000 for core, $55,000 for subcontracts  and  then  add
               20 approximately $70,000 for  the  phaseout of operational
               21 activities, you end up with $600,000.  And  I think that falls
               22 in the guidelines, shouldn't hurt them unduly in terms of staff
               23 and planning activities, give them some money for phaseout, and

               24 still the message should be there.
  Ice eal Repoiters,  Inc.  So I propose $600,000 as the figure.
               25




                                                                            19 7




                I           DR. @IAYER:  O.K.


                2           DR. SCHMIDT:  The Mover will accept that.

                3           MISS ANDERSON:  I second it.

                4           @IR. PARKS:  I would think if we are planning to

                5 extend this operation, that some consideration be given to the

                6 recommendations from the staff which are on this, what did

                7 you call the other color -- on these pink sheets -- which

                8 do contain some very.valuable suggestions, both on the  first

                9 page under recommendations and on page 2 of the critique which

              10  calls, really, for certain kinds of overall guidances and

              11  certain:kinds of technical assistance and support.
              12            I think, for example, if we are going to allow this

                  program to continue and   expect Dr. Glover to produce, it is
              13@

              14  then enc mbent upon RMP to provide him with all of the  kinds

              15  of support that would give him at least a chance to  succeed.
              16  I think that  ought to be considered in light of the money, for
              17  example, with $600,000 that has been recommended and also with

                  regard to the time period within which he is expected to
              18

              1 9 perform.
                            That is, to disengage him entirely, whatever has
              20
              21  transpired in the past, and try to give him some freedom of

              22  movement.
              23            SISTER ANN JOSEPHINE:  I think, too, it would be very,
                  very important if staff can to find this assistant for him,
              24
  kce   I Reportets, Inc. an adequate assistant, because to fill this role  effectively
              25




                                                                              19 8


                   is going to require a lot of hard work. And it is  going  to  be

                2 a very tiring thing. And I think  without  an  assistant  and

                3 without,the ability to delegate, you can almost  predict  it  is.

                4 notgoing to work.

                5            DR. MAYER:  Yes, Mr. Ashby.

                6            MR. ASHBY: Dr. Glover, I don't think  he  intends  to

                7  stay  more than two years. And'he is actively  looking  for  an

                8   assistant to train. And as I said before, he has  one  of  the

                9 biggest critics of thi s program. And at the  same  time,  if

               10 you consider the new coordinator, they have  been  without  a
               11 coordinator for 17 months. And then  you  limit  their  funding
               12  to an -@ount where.you can't operate.

               13            SISTER P-N-ii JOSEPHINE:  But he can plan.

               14            MR. ASHBY:  Right.  But it is like saying we are goinc,

               15  to  extend you for one year, Dr. Glover, although we  are  going

               16  to place these restrictions, and here is what you are  going  to

               17  come LP with. We know you are not going to do  it  because  you

               18  don't have the facilities and

               19            SISTER A14N JOSEPHINE: I think it is just  very,  very

               20  important you reflect the thinking of this group.  And  I  don't

               21  hear you reflecting@it now.

               22            DR. MAYER:  I am reminded of the comment that Bob
               23  Marston once made when there was a leveling off at $1.2 billion

               24  in the NIH budget. And everybody was having  at  him.  And  he

  kc   al Repofters,  Inc.
               25  said, "Well, you can still do a lot of research with $1.2 billic







                             And I would have to say that you.ought to be able

                2  to do a fair amount of planning with $600,000.

                3            Mac.

                4            DR. SCHERLIS:  I was going to say that is particularly

                5  true when you have $250,000 floating around that can be used

                6 for feasibility studies.  Most  feasibility  studies  I  have

                7  seen usually have been $3,000, $4,,000, $5,000 in the

                8  developmental component stage.  And these are in the range of

                9  $26,000 and $30,000 which to me is a major project and not

               10  just  core function.

               11            I think there is enough fat there to move.

               12            DR. SCHMIDT:  Concerning what Bill said, I think it

               13@  is impo tant to state the action of this committee as intended

               14  by me is.not to be vindictive, punitive, or anything else.

               15  But it is meant to be a directive and be just a little bit

               1.6 crisper than some of the actions and some of the things that

                   have been going on, particularly in that area.
               17

               18            It is clear there has to be certain things happening.

               19  And I think that there would be enough money with $600,000 to

               20  reach the end point that is, I feel, necessary  to  set  for

               21  this region.

               22            And the action of the committee is  trying  to  be

               23  helpful by setting an end point and giving some clear choices.

                             One of them is to make the case for   the  region,
               24

       ral Reporters,  Inc.
               25           DR. MAYER:  Yes, Phil.




                                                                                200



                I           DR.  WHITE:     It  seems  to  me  you  are  going  to  have

                2 difficulty doing what Sister thinks should be done if we are

                3 going to send this clear message you have a year to go or else.

                4 How in the world are you going to recruit that kind of guy  to

                5 come in and help Dr. Glover under those circumstances?

                6           Aren't you going to kind of have to suggest that

                7 Dr. Robbins or whoever is the head of the Cleveland Clinic

                8 or somebody lend some expertise, give them somebody on leave

                9 of absence from one of their institutions to get this thing

              10  moving? At least, he is going to have a job to go back  to  in

              I I case it 'f lops.

              12            DR  PIARGULIES:  We have some thoughts about  oiq we

              13@ might be'@ able to do that on a 3- to 6-months basis with someone

              14  who can really be of direct assistance.  But that is the

              15  dilemma.

              16            We have been carrying them on all this period of
              17, time saying, "liell, you know, if we just give them the chance,
              18  they will get the people and they will get things going."

              19  And it hasn't worked. So it is a situation in  which  whatever

              20  decision you make, you are going to feel a little uncomfortable

              2 1 with.

              22            DR. WHITE:  I think the point earlier was if Dr.

              23 Robbins -- I am not picking on him particularly -- but  if  the

              24 people in that region want to see this thing go, there is

  %ce  al  R@portefs,  Inc.
              25 @probably enough talent already in that area that they ought to




                                                                               2 0 1



                I  commit some of those hours of those people to  make  the  thing

                2  go.

                3            DR. IIARGULIES:  And if they can't find something

                4  that needs to be done in Cleveland, they are having great

                5  difficulties in their perceptions.

                6            DR. MAYER:  John, you had a conmient?

                7            DR. KRALEWSKI:  Back to this budget, I don't want

                8  to beat it to death, but I am sorry I  still  don't  understand

                9  it.  If we are recommending $600,000, what do we recommend as

               10  a start    this year?

               11            DR. MAYER:  September 1, 1972, to August 31, midnight

               12  1973.

               13            DR. KRALEWSKI:  And that will be consistent w3th

               14  the letter from Council?  Are we asking them to revise?

               15            DR. 14AYER:  Yes.  It can be made to be consistent

               16  with the letter from Council.

               17            DR. KRALEWSKI:  And the group here feels, I qather,

               18  there is enough information in this document  right  here  that

               19  we can make that $600,000 decision at the  moment  rather  than

               20  having maybe a small group with staff iron out  a  figure  here

               21  later'in the day?

               22            I don't feel I can, but if the rest of the group

               23  feels they are comfortable with it, I will go with it.

                             DR. SCHERLIS:  I would submit if yo u go through
               24

  ,ce   I  Repoitefs,  Inc.
               25  the entire application, you will come away with the same feelin




                                                                            202



               1  of restlessness.


               2            DR. MAYER:  Yes, Mac.


               3            DR. SCHMIDT:  Two comments.


               4            One, if staff or anybody has a better figure to come

               5  up with and want to justify it, I think it would be fine to

               6  reintroduce that later this afternoon or tomorrow.  And I


               7  think it would be considered.

               8            The second one is in my conversations with people

               9  at Caser Cleveland Clinic, Medical Society, and so on, they

              10 haven't got the foggiest idea of whether they want a Regional

              11 medical Program or what one is.  And I think at some point

              12 everybody from delightful what's his name in the Cleveland Clinil,

              13 on down have to get off this business of the Feds are going

              14 to keep putting money in here and we get plenty coming in

              15 anyway, and we don't need it.  Tiey have got to quit ignoring.

              16            And the big problem of getting a Regional Medical

              17 Program going in that area from what I have been able to see

                 is that people by and large have just ignored it.  And if this
              18

              19 is a way to get them to pay some attention, whether it is

              20 borrowing people from the university or whatever, then, fine.

              21 But people have to look at it and say, "All right, here is a

                 decision."  They have never really done that.
              22

              23            DR. MAYER: Does everyone understand the motion?

              24            MR. PARKS: One question.

  ce   I Repottefs,  Inc.
              25            DR. 14AYER: Yes, Mr. Parks.




                                                                                20 3



                             MR. PARKS:  On the recommendations from the staff

                2 anniversary review panel, there is  a  rating  of  245.  May  I

                3  ask what that means-and on what scale?

                4            DR. MAYER:  That is on the 6iie to five scale, I

                5  assume.  That puts it in group C which is the lowest grouping

                6  which at-least says something,  but it is at least barely in

                7  there.

                8            MR. CIUMLISS:  If   I may make a  comment  there  --

                9            DR. 14AYER:  No, I am-sorry, it must be .1111.

               10            DR. BESSON:  It runs from zero to five hundred.

                             DR. MAYER:  Yes, right.

               12            Yes, Mr. Chambliss.

                             MR. CHAIABLISS:  I was simply going to let the comnitt
               1 3
                                                                                le'
               14  know that the desk chief, Mr. Van  Winkle,  would  be  availab
               15  to answer any questions on that  if'you  have  further  questions.

               16            DR. MAYER:  O.K.
               17            Comments?  Everyone understand the motion?

                             DR. SCIFERLIS: Is there any feeling  of  staff  that  we
               18
               19  are misreading the signals?  I am curious.
               20            DR@ MAYER:  All I have heard is a feeling that
                   the therapy may not be appropriate.  But  I  think  the  diagnosis
               21
                   sounds pretty aood with everyone. At least,  that  is  what  I  am
               22
               23  hearing.
                             MR. CHAI@IBLISS;  The comment from staff  would  be  that
               24

  @ce   I Reportefs,  Inc.
                   I feel the diagnosis is quite  proper.  Ile have some concerns,
               25




                                                                             204



                  great concerns, about this region.

                2           DR. 14AYER:  Sister Ann.

                3           SISTER ANN JOSEPHINE:  May I just make a comment

                4 to you sitting at the end of the table after you were so  nice

                5 to brief us in.  These are the kinds of pressures I get from

                6 my board,  And several years ago, I was saying this is too

                7 harsh a'way of doing it.  You know what? I am learning  it  is

                8 a good management tool.  You will be surprised how many good

                9 things can come out of it. But I do know that it  is  terribly

              10  important that you share our feeling about it.

              11            This is really a measure to make it possible for them

              12  to get moving. And so you will have to be very  supportive  of

              13  it because they will read it very quiclzly.

              14            MR. ASHBY:  I want to apologize. I was talking out

              15  of school@,

              16            DR. MAYER:  Further comments?

              17            Yes, @e.

              18            MR. VAN IIINKLE:  I think one of the major reasons for

              19  their problem out there is the fact their executive  committee

              20  and board of directors are one and the same.  And that largely

              21  reflects Dr. Charles Hudson's thinking. And I am  hoping  that

              22  when we get this new piece of paper that tells us what the

              23  RAG relationships and coordinator relationships and these

              24  sorts of things are, we can put sufficient pressure on them to

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              25  change their by-laws.





                                                                                205


                 I           But that is what is a real grievance  out  there.  And

                 2  they are dictating, there is no question, the executive

                 3  committee and board of directors are the same, and they are

                 4 dictating to the coordinator or non-coordinator.

                 5           DR. 14AYER:  Other comments?

                 6           (No response.)

                 7           All those in favor o f the motion say, "Aye."

                 8           (Chorus of ayes.)

                 9           Opposed?

               10            (No response.)

               11            We effectively have gone past coffee, but let's

               12  take about a 10-minute break to mark the sheets and stretch.

                             DR. SCHERLIS: Just one sentence that  I  think  under-

               14  lines w at you said.  The organizational structure is apparently

               15 not well@understood, and it is amplified as it goes  on  in  the

               16  next few pages.

               17            (whereupon, a recess was taken.)

               18            DR. IIAYER:  Could we start, please? Are we ready,

               19  John?

               20            DR. KRALEIISKI:  Right on.

               21            DR. 14AYER: This is new. It  isn't  anniversary,  but

               22  was site visited.

               23            I might comment before John begins that what  we  have

               24  just done in terms of Northeast Ohio, there was a  SARP  rating
  @ce eal  R'eporters,  Inc. in which the question was appropriately raised about  what  that
               25





                                                                                206



                 I  meant.  And then we proceeded to go on to rate it.

                 2           I think what we might do in those  that  have  already

                 3 been rated by SARP, we need to make a first  decision  which  is

                 4 do we agree with the rating.  And if we say, yea, then we

                 5 stop there and go no further in terms of subratings.  If we

                 6 say that we do-no-L. agree, then I think we are saying that we
                 7 want to@,,also rate itt and we ail rate it.

                 8           John, we knew you were coming up because I assume

                 9 that is your material on the blackboard.

               10            DR. KRALEIISKI:  Right on, yes, indeed.

               11            DR. SCIUIIDT:  Were you asking a question or making a

               12  comment?,

               13'           DR. MAYER:  I am making a statement  unless  you  want

               14  to approach it otherwise.

                             DR. SCI-LAIDT: I think we should rate tJie region.
               15

               116 Is that what you were stating?

               17            DR. MAYER:  Yes.

               18            Well, maybe we need to take a minute.

               1 9           DR. SCHMIDT: I think staff  rated.  I  think  that  is

               20   beautiful. I think we ought to rate  it, too, as a committee.

               21            My gut feeling is that staff's numerical  score  is  a

               22  little bit high, although I agree with the comments and

               23 suggestions.

               24            Am I out of order?  Am I talking about something

  kc   al Reporters, Inc.
               25 lelse?





                                                                                 207



                 I           DR. MAYER:  No, it is a question of        Well,  let

                 2  me go back.  When we originally talked, and I don't know

                 3  whether I am two meetings back, one meeting back, or three
                 4 meetings back, when we were talking r@ting scales, we    said

                 5 that those which are anniversary  reviews  within  the  triennium

                 6 would be handled by the staff  anniversary  review  panel,  SARP,

                 7 that we would also comment on  those  and  discuss  those.  And

                 8 then the question came in terms of how much time would we spend

                 9 on them and would we rank them, etc.

               10            And I think where we were was to say, "All right, we

               11  will look and see what the staff anniversary review panel

               12  which was set up to do that job does, and if we agree with the

               13  figure that they are at, fine.  And if we don't, then we owe

               14  it to ourselves to go ahead and rate them.'
               1 5           DR. SCHIL4IDT:  Are you talking about the 245   score

               16  that was brought up before?

               1 7           DR. MAYER:  Yes, for Northeast Ohio.

               18            DR. SCII14IDT:  I would be uncomfortable with matching

               19  my motion against that point score.

               20            DR.' @IAYER: And we therefore rated  it.  So  I  have

               21  no problems with that. All I am saying  is  we  need  to  address

               22  ourselves with each of the applications which   on  this  sheet

               23  have numbers.  We have to address ourselves do   we want to

               24  accept that level or do we want  to  rate  them  ourselves?  That
       al R@porters,  Inc.
               251 is all'I am suggesting.




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                                                                               2 0 8



                 I           14aybe what you are saying is you want to rate them

                 2 all.

                 3           Yes, Leonard.

                 4           DR. SCHERLIS:  I  think having this sheet in front of

                 5 us  makes us focus on individual items as they are presented.

                 6 And as s'uch, it is a very good way of focusing the attention
                 7 of the 'group,  In so doing, a rating is arrived at.  And I

                 8 would think we should do this with  each  presentation  that  is

                 9 made  here.

               10            I find it difficult to accept another rating without

               11  going through the mechanics myself to see if I agree.  But
               12  once I  hI@ve done the rating, then it is there and it is written
               13  and some@hing might as well be done with it even if the
               14  committee that goes over this chooses to disregard it.  But at

               15  least I would like to go through the mechanics of doing it.

               1 6           DR. IIAYE R: O.K., does staff have any troubles   with


               17 that?

               18            DR. SCIU.IIDT:  If there are great discrepancies in

               19  this rating and staff's rating, I think that is  a  nice  danger

               20 .signal that would signify we have got a-problem that ought to be

               21  looked  at.

               22            DR. BESSON:  I  have viewed this as just your calling

               23  the presence of this rating to our attention, no more.

               24            DR. 14AYER:  All right.

  kce -deal Repotters,  Inc.
               25            DR. SCIU4IDT:  You got that?




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                                                                             2 4 3



                I           And those eight recommendations are outlined on

                2  the secondpage of the site visit report that you have.

                3           The region at the time  of our earlier visit had.just

                4 come through the process of separating from the  South  Dakota

                5 component, just reformed as a separate  Nebraska  region.  And

                6 there are some problems relating to that.

                7           We found that there were some very fundamental

                8 problems in terms of program management and direction.  And
                9 these eight points which you see outlined on the site visit

              10  report addressed those issues.

              11            I could say that in summary all of these issues,

              12  that this advice letter had been taken very seriously, that
              13  shortly after the receipt of the letter, the program coordinator

              14  resigned, and very shortly thereafter a new coordinator  was-.

              15  appointed.  He had been with the PJ@IP previously.  And by
              16  September of last year, the RAG had sort of reformed  itself),

              17  and they were down to brass tacks and working.
              18            And most of this past year has been devoted to
              19  reorganization, reforming the region and trying to address
              20  those questions and suggestions which were raised in this advi--@-,

              21  letter.
                            The newly appointed coordinator is proving to  be  a
              22
              23  good.coordinator.  He has@shown the ability to provide
                  directions to RAG. Many of the actions of the  RAG  have  been
              24

  kce eat  Reporters,  Inc.
              25 upon his advice, and they have acted on it and not hesitated to





                                                                                 24 4



                    reaat to his leadership.

                 2
                               He has made a number  of  rather  difficult  decisions,

                 3
                    one of them being that  some negotiation with the medical

                 4  school and the core funds now were under his direction instead

                 5  of under the medical school's  control.  And  I  think  that  kind

                 6  of action is indicative of the  strength  of  leadership  that  he

                 7  is providing.

                 8             The RAG is playing a much more  active  role  now  than

                 9  they  used to,,

                10             DR. MAYER: Joe,  can  you  use  the  microphone?

                11             DR. IL-;SS:  The RAG is playing a much more active

                12  role  than they formerly had in setting program policies,  They

               .13  have reorganized themselves into five working committees,

                14  an executive committee, nominating, the budget and finance

                15 and the  resource  and  development  and  operations  review

                16  committee.  And each of these appear to be performing their

                17    functions.

                18             The program has developed  documents  which  spell  out

                19  the  proce dures whereby  rojects are to be reviewed,.    And  the
                                            p

                20  relationship between the gt@ntee and the  RAG  and  all  of  these

                21  kinds of things, all of those issues were appropriately

                22  addressed.,

                23             They have had a management consultant from the

                24  University working with them,  and  they  developed  a  new

  .Ace deral  Reporters,   Inc.
                25  organizational structure and developed job descriptions of each




                                                                             245



               I of the positions. And in terms  of  program  management,  there

               2  has also been much strengthening.

               3            I would also indicate that the morale of  the  staff

               4  which is one indicator is much different than it was a year

               5  ago. A year ago, we had indications in  talking  with  members

               6  of the staff informally there just was no communication,  that

               7  they were not working together, that the coordinator wasn't

               8  listening to them and so on.  But you get an entirely

               9  different feel this time. They  were  working  together.  They

              10  felt they were part of the team and that everyone seemed to be

              11  unanimous in the feeling they had made a rather  major  change

              12  in direction and  function.

              13            As far as identification of regional needs is

              14  concerned, there was one survey which we learned about a  year

              15  ago which still is the major syste matic survey that  they  are
              16  using.  This is supplemented, however, by the information whic.-,
              171 was picked uo by the R.14P staff in the visit throughout the
              18  Nebraska region. And you can perhaps see from the  little  map
              19  they have in the v'ellow pages, they have project activities

              20  that pretty well blanket 14ebraska. So they do get out and  do

              21  spend a lot of time out in the community.  And that supplements

              22  and is one of their sources of gathering information.
              23            But another important thing which at least  has  the
              24  potential of having made their impacts in terms of needed

  @,e eal Reportefs,  Inc.
              25  identification is the study which has been carried  out  under

                 I




                                                                                246



                 I  the cliP agency which will be in its completed  form  in  June.

                 2  And in talking with the AAuc director who is a very intelligent

                 3 dynamic woman, already there are things  coming  to  the  surface

                 4 in that study that are going to have an impact on what  R-7,IP

                 5 does. And they seem to be  open,  their  communication  is  good,

                 6 their relationships appear to be quite good between those two.

                 7 So I feel quite confident that that study  will  result  in  some

                 8 change in their objectives and priorities in the months ahead.

                 9           The  question of phasing out of  the  programs,  this

               10  has  begun. And they are aware of it, and  they  intend  to  do

               11  more.  There  has been some joint funding  now  through  other

               12  IU4Ps around. them.  The university is beginning to pick up

               13  certain projects which can be justified  and  so  on.  So  that

               14  they areraking movement in this direction.

               15            The final issue in that letter has  to  do  with  the

               16  mobile cancer project.  The core staff has been actively
               171 involved, and the R7iG al so, indirecting the course of the
               18  cancer project. And it seemed-to us  that  they  seem  to  have

               19  these fairly well in hand.

               201           Going on with the report,  they  have  redefined  their

               21  goals  and priorities.  They look quite different than they did

               22  a year ago.  And they are consistent with national goals.

               23            14ost of the projects which have  come  through  the

               24  review process now tend to be ones which conform more with the

       al Reportets,  Inc.
               25  older mission of @IP than the newer. And  as  near  as  we  can





                                                                                 24 7


                   determine, one of the reasons for this is that much of the
                2  core staff activities and so on, the RAGS,  have  been  in  this
                3  reorientation process. They haven't had  time  to  get  out  and
                4  stimulate development of new projects.  But  they  seem  to  be
                5  aware of the need to do that.  I think the chances are

                6  reasonably good they will do so.
                7            We mentioned continuing support.
                8            Minority interests, these are not very well reflecte--',,
                9  but they have told us they have  tried  to  get  more  minority
               .10 representation and will continue to  try.  As  we  talked  with
               11  the lady who is the CIIP director, it seemed she had some
               12  ideas and techniques for doing this that perhaps they
               13  could learn from. And we suggested  they  might  talk  with  her
               14  and get  some  as.sistance from her in doing  so.  But  at  least
                 I there was a willingness, @nd we indicated  that  we  hope  there
               15
               16  would be improved performance as well.
               17            I mentioned already the  coordinator  in  relation  to
               18  the RAG.  The core staff seems.to be quite strong,  In working
                   with the management consultant, they have identified the need
               19
                   for some additional staff positions -- one  in  the  area  of
               20
                   bolstering their program evaluation  segment  and  others  in
               21
                   area consultants. And after  hearing  the  rationale  and  so on,
               22
               23  we concurred with that.assessment and agreed they should    furthe,-
               24  strengthen the core staff.
  4ce  eal fzeportefs, Inc.  The Regional Advisory Group still tends to be
               25




                                                                                    24 8



                 1  provider dominated, but there has been some change in the

                 2  balance since  we were'tliere a year ago.  They seem to be

                 3  aware and were receptive to our suggestion that they need to

                 4  give further attention to a broader representation on the RAG.
                 5            The grantee organization  is  the  State  Medical  Society.

                 6 I think there has  been  -significant  movement  in  the  relationship

                 7  between grantee and RAG, the PJ4Ps, since we were    there a
                 8  year ago.  I think there is still some further delineation
                 9  refinement that needs to be carried on there, but certainly

                10, they are moving in the right direction.

                11            We pointed out some of the areas which we thought

                12  they needed to give further attention to.  And I would hope

                13  that.these further additional. details will be attended to.

                14            Their-participation, we mentioned, in terms of RAG
                15  participation and so  on.  The  State  Medical  Society,  physicians,
                16  seem to be the majority, but there is good participation in the
                17  State Health Department, appears to be good working relation-

                18' ships there.
                              The CIIP seemed to be reaching out in the communities
                19
                20  to a considerable extent, and their record is reasonably good

                21  in that area.
                22            Hopeful planning, they are working with CIIP B  agenci----z
                23  that exist, but that program was just beginning to get geared
                24  up.  They have some of their own local mechanisms for doing it,

  Ac   derat  Reporters,  Inc
                  ' but I think again their performance is satisfactory.
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                                                                              249



                             We have talked, I think, enough  about  management.

                2            The evaluation has improved substantially  since  we

                3 were there a year ago. We agreed there is  a  need  for  more

                4 staff in this area. And this function in  this  area  has  been

                5  hampered somewhat by the ill health of their evaluation

                6  person. But I was filled in this morning  they  have  already

                7  taken steps to bolster this area, and they recognize  the  need

                8  for further improvement.

                9            The action plan, again, is more in  the.forroative

               10  stages because of this reorganization they have  gone  through.

               11  They have their goals and their priorities developed  now,  and

               12  I would anticipate in the next few months, we would  see  an

               13  action plan based on those goals and priorities begin to appear

               14  in terms of projects more related to that.

               15            They have been successful in the area of disseminatio;-

               16  of knowledge. They have had coronary  care  training  programs

               17  and other educational type projects which have apparently been
               18  well received and have served a real need and have  been  the
               19  means of bringing inactive nurses and other people  back  into
               20  the health care system. And there have been a  lot  of  spinoff
               21  benefits from the projects that were built  as  dissemination

               22  of knowledge.
               23            Manpower and facilities, there have been some,  as  I
               241 mentioned, spinoff benefits from the coronary care  and  other
  @c   al Repofters,  Inc.
               25  type education activities which have had an impact  on  this.






                I  But we really were unable to get a very good handle on just

                2  how much impact the W4P is having on use  of  those  facilities.

                3  They have stimulated cooperative  arrangements  among  hospitals.

                4  There is sharing going on as a result of  these  @IP  projects.

                5  So we got the feeling that they have had some impact.

                6            The improvement of care, I think what  I  have  already
                7  said   miore or less summarizes what I want to say  in  this  area.
                8            Short-term payoff, I think there has  been  some  with

                9  the coronary care learning resource  center.  They  have  plans

               10  for more regionalization in the sense they  are  developing  area

               11  coordinators who are going to work in specific areas within

               12  the region to stimulate more cooperative  arrangements  and  more

               13  joint activities in  that  area.

               14            In summary,  then,  we felt that the region had
               15  seriously addressed all  of  the issues v7hich have been  raised
               16  as a result of the  site visit of last year and has made  vo_rv
               17  substantial progress  in  making the necessary changes in
               18  reorganization and changing the direction of the @%IP.-
               19            As a result of this, we came up with a funding

               20  recommendation of $725,000.
               21            Now, that.is based in part on  the  recommendation  of
               22  the Kidney Review Panel that neither of the kidney projects
                   ought to be funded.  And  one of the important reasons  is  they
               23
               24  had not  develope.d a well-thought-out regional  plan  for  kidney

  AC    al Reportets, Inc.
                   disease.  So that accounts for one of the major reductions
               25




                                                                                251



                 I below their request.

                 2           And we felt that there were  some  savings  that  they

                 3 could make in terms of the mobile cancer unit  and  one  or  two

                 4 of the other  projects without hurting them and also that

                 5 some cutbacks should be made in the funding of current

                 6 projects to give them some seed money for feasibility studies

                 7 and so on to start off and do some planning at least in the

                 8 new directions which they want to go.

                 9           So.that this was the  rather  simplistic  rationale

               10  for arriving at the recommendation for $725,000.  We recommend
               11  that the  find within that budget about   $25,000 for initiating
                           y

               12  some small,planning feasibility studies,  mentioned  the  two

                   kidney disease activities, and we felt that  they  should  be
               .13
               14  given the option to submit a triennial application next year,
               15  feeling that with another year to work  and  develop  that  they
               16  may be in a position to merit that.

                             DR. 14AYER:  Dorothy, cor"-nents?
               17
                             MISS ANDERSON:  I was amazed, just reading   the materi-@
               18

                   I v7asn't on the site visit    at the progress  they  have  made
               19
               20  in just six months with this new  coordinator.  And  I  think
               21  this is a real good example where rather than getting the
               22  person to change their thinking  in  coordinators  and  changing
               23  their action that maybe vie do need to look seriously and
               24  encourage some areas, .regions, to get new coordinators.

  kc   ral Reportefs,  Inc.
               25            Now, I was impressed by  the  involvement.of  the  RAG




                                                                               252



                I  group,  They really got involved in committee meetings.  They

               .2  were involved in site reviews and made recommendations for

                3  changes of budget and relocation and  reallocation  of  money,

                4  as I understand.

                5            They have also changed their by-la;,7s and realigned

                6  budgets and did other things that  really  showed  involvement

                7  of the group.

                8            I was interested that the staff kept relating to

                9  a 1968 survey that was done.  And I had a feeling that maybe if

               10  the staff had been out in the community  more,  they  wouldn't

               11  have to wait for this new survey for some direction.,

               12            DR. HESS:  I think maybe that is an unfair reflection

               13! of the report because the staff is out in the community.  Thev

               14  get very high marks for being out and visiting around.  T ey

               15  really ride the circuit.

               16            IIISS ANDERSOii:  It seems like they have quite a few

               17  things they are holding off until they get  this  new  survey.

               18            DR. HESS:  That may be more a reflection of our

               19  report than it is in reality. I am not  sure  that  is  really

               20  fair.

               21            I-IISS @IDERSON: Thank you.

               22            Another area I thought was interesting was the
               23  development of the new goals in regard to  the  new  direction
               24  that R:.IP is going in regard to health manpower, health  care

  %ce   I Reportefs,  Inc.
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                                                                              253


                             I think everything else we have touched  as  far  as

                2  I can  see.

                3            DR. HESS:  Just to elaborate on one point that you

                4  picked up and I forgot to mention is that the  RAG  is  involved

                5  in the site visits-to projects.  I think this is a very

                6  tremendous thing. At least some member of  the  RAG  has  some

                7  detaile d knowledge of nearly every project.  And  that  is,  I

                8  think, rather unique.   I don't know. There may  be  some  other

                9  regions, but offhand I  can't recall others that have that

               10  degree of involvement of the RAG.

               11            14ISS ANDERS014: And I think another point  I  would

               12  like toisupport you in is in-regard to representation on the
               13  RAG.  Th, ey do need more minority people.  There are many
               14  indians,as an example in this area.  And blacks also.

               15            And, also, they need more allied  health  people  on

               16  their RAG from what  they  hav.e had in the past to make it,

               17  if you are thinking of comprehensive health care.

               18            DR. MAYER:  Dr. Hinman, comments?

               19            DR. HIN,@@4AII: Yes. This region had two  applications

               20  in for support of kidney activities.  They  both  had  technical

               21  review in the region by people from within the region who

               22  made strong recommendations against the appropriateness of the
               23  proposals. And on that basis, it  is  the  staff  recommendation

               24  it not be approved even though the RAG sent them in.

  @ce  al Oeporteis,  Inc.
               25            one of them was to produce six films of teaching




                                                                               2 5 4



                I  tapes of undetermined type for an undetermined audience.  And

                2  the other was to train'some people for we didn't know exactly

                3  what in the application.  So it was our recommendation that
                4 the region be given advice  that  there  were  existing  guidelines

                5  that could have assisted them, staff  could  have  assisted  them,

                6  there were new guidelines coming out, and we recommended

                7  disapproval.

                8             It was $48,838 requested.

                9             DR, MAYER:  Further comments?

               10             DR. KRALEWSI"I:  I have a question about the core

               11 staff. How many people do they  have  and  how  was  this  affected

               12  when they split apart and all   that? Are they  saving  any  money

              -13  or what is happening to the core?
               14             DR. IESS: Well, you mean  when  South  Dakota-Nebrasl:a

               15             DR. K@EI-O'SKI.  Yes.
               16             DR. HESS:  They decided there was a division of   funes,

                   and so on  that was negotiate d witli.PJIPS.
               17
               18             DR. SCH14IDT:  I think the answer is in light of the
               19  activity,  the core type of activity, was  really  Nebraska  and
               20  South Dakotals problem is really to build up.  The flow was
               21  into -- at leastr I was representing South Dakota at that time -
               22  the flow was kind of into Nebraska.  We  had  a  core  staff.  I
               23  don It think they are cutting back any.  The loss of South Dakota,
               24  there wasn't much in South Dakota there.

  Ace deal Reporters,  Inc.
               25             DR. KRALEIQSKI: This budget expands  that  core  now,




                                                                      255




               I does it?

               2          DR. HESS:  I-would have to go back and look at the

               3 figures ayear ago versus now.

               4          DR. 14AYER:  Yes, by about $140,000.

               5          DR..HINMAN:  $232,000 to $376,000.

               6          MR. POSTA:  I might make the statement here I

               7  think the core budget as outlined here for this upcoming year

               8  really indicates the inclusion of four new members to the

               9  staff.  But in view of the fact that the drug information

             .10  center and resource learning center that was appointed a

             11  project last year would be included under the core,.I think

             12  would be increased for the next year total within core is about
             13  $115,000 rounded off.  And that would take care of assuming

                 those two new programs or the two old programs and a couple of
             14

             15  now additions to the core staff.
             16           DR. K@-LEIISKI:  Now many vacancies do they have?

             17           MR. POSTA:  Frank.
             18           MR. Z,-IZLAVSKY:  They.are requesting four full-time
             19  positions   deputy coordinator, associate coordinator for
             20  evaluation, and two additional area consultants.  And this
             21  totals about $70,000.  $20,000 increases for fringe benefits.
             22  Previously.under the previous coordinator, fringe benefits were.
             23  non-existent.  This is something they have been fighting for
             24  three years.  They have finally established it.
 Ac   rat Reporters,  Inc. That speaks to about $100,000. They have a couple of
             25




                                                                                256


                I  pha@acy students on part time answering the phones 24 hours
                2  a day which speaks to abou@ $10,0'00.  That  accounts  for  about

                3  $110,000.

                4            We have got a little bit more  money  in  travel,  a

                5  little additional money in equipment.

                6            DR. HESS: I think you  are  asking  how  many  existing

                7  vacancies.

                8            DR. KRALEWSKI:  Right.

                9            DR. HESS: And I  don't  believe  there  are  any.  They

               10  are all ne@q ones that they are asking money for.

               11            DR. I-IAYER: Four  new  professional  positions,  is

               12  that what you are saying?

               1 3           MR. ZIZIAVSKY:   Right.

               14            DR. IIAYER:  Further comments?
               15            DR. HESS:  I would move-formally, then, they be
               16  ao;oroved at $725,000, and we also felt we ought to make a
               17  tentative recommendation for $700,000 for the second %,,ear so
               18  they have something to plan on, but  with  the  understanding  --
               191           DR. i4AYER:  They will probably be coming in with a

                   triennium.
               20
               21            DR. HESS;  That's right.

                             DR. @IAYER:  But in case they don't, we are recommends
               22
               23  $700,000.
               24            DR. HESS:   Yes, some sort of  assurance  for  them.
  Ac   ral @eporters,  Inc.
               25            DR. I.IAYER:  O.K., is there a second to that?








                             MISS ANDERSON:  I second it.


                2            DR. MAYER:  Furtl-ier comments?


                3            Yes, John.

                4            DR. KRALEWSKI:  A point of clarification.  That

                5 $25,000 is included?

                6            DR. HESS-.. In the $725,,000.

                7            DR. SCHMIDT:  I am curious about this renal business,

                8 Dr. Hinman.  You said that the RAG approved it, but that people

                9 within Nebraska recommended disapproval?

               10            DR.  HINMAN:  There was a technical review by three

               11 physicians from within the State who had adverse comments the

               12 program was not adequately documented, adequately structured,

               13 and they still sent it.
               14            DR. SCHMIDT:  From the university or Creighton or.-'

               15            DR. HESS:  One was Dr. Holmes from Colorado.  They

               16 were experts, kidney experts, that were called in.  But they

               17 were not all from without Nebraska.

               18            DR. HINILKN:  Two of them were, weren't they?  You

               19 are right  about Dr. Holmes, but I thought the majority were

               20 from with@Ln Nebraska.  But either way.

               21            DR. SCHi4IDT: It was on technical grounds that it was

                  turned down, then?
               22

                             DR. HINMAIN:' Yes.
               23

                             DR. MAYER:  Technical plus regionalization, I was
               24

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               25 hearing, Mac.






                                                            DR.  SCE14IDT:     I  know,  but  you  see  the  RAG  approved

                                  2 it.


                                  3                         DR.  IIINMAII:     That  is  correct.

                                  4                         DR.  MAYER:     In  spite  of  the  negative  comments.

                                  5                         DR.  HINMAli:     Yes,   sir.

                                  6                         DR.  MAYER:     Ilhich  makes  the  point  we-were  trying

                                  7    to  make  earlier.


                                  8                         O.K.,   further  comments.

                                  9                         (No  response.-)

                              10                            All     those  in  favor  of  the                     motion?

                              11                            (Chorus  of  ayes.)

                             .12                            opposed?

                              1   3                         (No response.)

                              14                            Before we break, I have got a couple of issues I

                              15      want to comment about. The first relates to this evening's

                              16      activities, to make sure we all understand where we are going
                              171     and how we are going to get there.
                              18                            (Announcements ..iere made.)

                                                            DR. IIAYER: one of the individuals who has been
                              19
                              20      participating in P-14P applications as long as anyone, including

                                      maybe myself, Lorraine Kyttle, who is on my right, who has been
                              21
                              221     serving us very effectively for the last three years, four
                              23      sessions of this committee, this is also her last review

                                      committee session. She is going to be assuming responsibility
                              24
    @ce          I Repoiters,  Inc.   for South Central Operations Areas which will include Memphis,
                              25




                i@ Illj:nois and South Carolina as her activities, but will not
                2 be serving in the capacity  ,she has.  So I just wanted to

                3 indicate to you this evening while we are there that it is

                4 also her last go viith the committee.

                5           On the agenda for time, I will not be with you

                6 tomorrow. My chancellor has called a budget  session  which  I

                7 have to be at if I hope to survive for tomorrow.  And  I  will

                8 have to go back tomorrow.    But there were two items or three

                9 items that were on the suggested items for the agenda  that  I

              10  wanted to remind you all about so that you didn't forget them.

              11            one was the, if I may call it that, emasculation

              12  issue which Jerry had raised and others had raised that we

              13- needed to talk about a little further.

              14            The second was Mr.  Parks raised the question

              15  appropriately about several of the.questions that we sent.

              16  up to the Council at the last meeting, and we need to discuss

              17  a feedback of those.  And I assume, Mr. Parks, you will raise

              18  those tomorrow.

              19            And then thirdly, there was sortie discussion of at

                  least some of the people at lunchtime about new members of the
              20

              21  committee and new chairmen, vice chairmen, etc.  And  I  think

              22  that issue needs to be raised.

              23            And with that, I would like to say it has been my

                  very real pleasure having an opportunity of  participating  in
              24

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              25  this committee over the many years and chairing it the last





                                                                               .GVV



                   two years almost in toto.  I appreciate all the efforts that

                2  have gone on in terms of helping us get through  and  the  job

                3  done.  it has been done very well.

                4            DR. SCHERLIS: I  think  somebody  should  recognize

                5  the fact that you are not being here tomorrow,  this  is  our

                6  last opportunity to formally thank you for, I  think,  what  has

                7  been not just superb direction, but maintaining our good

                8  humor and I think giving us a sense of at  least  thinking  we

                9  know where we are going. And I want  to  on  behalf  certainly

               ,lo of the committee extend to you our  thanks  for  having  been

                   such an excellent chairman o ver the years.

               12            DR. 14AYER:  Thank you very much.

               13            DR. KRALEV7SKI: l.'would like to formally move  that

               14  into the minutes.

                             DR. BRII;DT ry:  Second.
               15
               16            DR. BESSON:  I move it  up to the Council.

                             (Laughter.)
               17
               18            DR. 14AYER:  That is really a policy issue.
                             Well, I hope to see most of you this evening at
               19

               20  6:30.

                             I would also like to remind you  do not  forget  those
               2 1
               22  of you because I didn't remind you in Nassau-Suffolk as well
               23  as Nebraska in terms of your rating sheets.  And I would
               24  assume that if you held onto those, fold it up neat  y  at  your
  kce   I Repottefs, Inc. place so people aren't seeing them. I think you  are  probably
               25




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                I  in good shape.  We can leave the materials here.

                2           What  time, 8:30 in the morning?  I think we can

                3 probably appropriately move it along.

                4            (Ilhercupon, at 5:10 o'clock-p.m., the meeting

                5 recessed, to reconvene at 8:30 p.m. on Friday, May 5, 1972.)

                6


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