i3 I Ill'o i . l@i I i ii i11 it i i, :I I , , . i@ ; II!,,i ii R I N A L Transcript of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE RLGIOI,IAL V'LFDICAL PROG-WI SERX7!CE COUNCIL @gif%ETING POckville, Maryland Ilednesday, 10 Novo.-,ther 1971 ACE-FEDERAL REPORTERS, INC. Official t7eporter,@ 415 Second Street, N.E. Telephone: Washington, D. C. 20002 (Code 202) 547-6222 NATION-WIDE COVERAGE 41 @8 I.BS DEPARTMENT:DP HEALTH, EDUCATION, AND WELFARE 2 19@ 10 - REGI MED PROGRAM SERVIdr., COUNC L MEZT'±NG 14 15 Conference ROOM GH Parklawn Buildi 16 5600 Fishers Lane Rockville Maryland 17 November 9 Wednesday,, 10 71 L9 20 22 23 24 95 2 c 0 N T.,E N T S 2 AI?PLICATIONS@.- PAGE. 3 Indiana 3 4 Virginia 4 5 Iowa 6 New York Metropolitan 14 7 Tennessee/m -So th is 8@ Wash 9to /A ska 30 n 9 West vii in a 38 10 @'Missouri Special Action 41 11 OTHER: 12 Cancer Center in Region X 65 1Z KIDNEY PROP6$ALS:@ -Ora @71 15 Oh:o Valley 16 Iowa 77 17 Cal3'.fornia,// 80 Georgia @v,' 6 19 Rochester 20@ 21 24 3 P R 0 C E E D I N G S 2 DR* PAHL-. May we come to order for the morning's 3 meeting, 4 We have a reasonable amount of business on the 5 applications, but if we proceed in good order I suspect we 6 can :finish before we get too far into the early afternoon, 7 s we start this morning a ndianet nd I would, mqgest that with@t 8 triennial icat'on with Dr. Brennan as the@principal reviewer and%Dr,,Musser as the backup reviewer,, and Mr. 10@ Torbert as staff resource indivi a]'; ng th and fol@lowi at icat then procee we 'Will1i d with the Virginia ap litation p 70 and I'WOUld appreciate knowing if there Are early departure 13 contemplated b other council erg so tha be able meinb t we'll 14@ to rearrange matters but please don't all de rt. pa 15 'Dr. Brennan would you like to proceed with the 16 Indiana findings? DR. BRENNAN-: 1 will move that the recommends ions Of the Review ittee and the Site Visit Committee, which are identical, be adcepted by the-Council. 20 DR. PAHL.-, Dr. Musser is not here at the moment. 21 Is there a second to the motion? 22 MRS. F Second. DR. PAHL: The motion has been made and seconded 24@@ to accept the Comitteals recomendatioh on the Indiana 25@ application@on the triennial application. Is there discussion 4 by the Staff? If not, All in favor of the motion 2 @please say "Aye." 3 ;4 DR. PAHL: Op osed? p 5 (No Response) DR@. P L:@.The motion is carried. 7 me li@ Si d Dr. Sehreiiier.:have; nce you an 8 both had the op t ity now to review al @f th kidney por un 0 9 9 aspects and since this motion did include 4,.kidney 10 @dation, it is my un standing that the motion i@ii@@cludes,'with your concurrence* the kidney proposal; is, that cortect?'-@, 12@ DR* MEPMLL: Ye,,- D PAHL,., Okay. 14 e l(Vircjiniafapplication,,@ i aan a= sa ication, with Dr. Everist as prin pal l@6 reviewer and Mr.@Hines as backup reviewer and Mr, Hinkle f rom our 0 DP,. PIST: This is an anniversary continuation 19 ant on.for@the 01 operational ye :-that vas,site ar 20 visited @@.bv re ewer a others on September 13@ last. This,@ plication@has not had a staff anniversary 22 re pa @.Ot has been reviewed by the Re 23 Comittes@p is general agreem@ent@between the site 24 ttee's report- reg has 25, had a slow start@wi the original grantee designated as the Medicine in Charl-o 3 ille,, University of ia Schoo3. of v 7 2 then changed to the Medical College of Virginia in Pichmond,, 3@ now known@as@ e Virginia Commonwealth Univergityol a d in 4@, March of 1971 the grantee became the Virginia Recjional@ 5 Medical Program, Xnc. 6 The region has,,had a developmental component 7 disapproved i 'February 1971 review cycle; and this marks the site visit the,:differ between the-,reoormendations of 9 am and the Rev Comm although the site team,did t @io ld to itment for the developmental componen r a z. the-di -to await fu her information from Doctor P re recto of the regi T ,Virginia Re oha@ Medical Program has had a 14 rather dif:fi roe establishing good rapport with the medical es lighment in Virginia. They have done this on the 1 6 basis of categorical emphasis and are how accepted As a 17 viable agency. The redirection of Regional medical Pro rams :18 has caused@some.difficulty in Virginia,, and we were appraised 19 of this w freshinq candor, by@the director. De its 20 the,diffi lties, the region has accepted the challenge and 21@ Will proceed. Albeit cautiously, into this decade,.. R@ver,, 22 at the moment,the progr= is categorical; the projects are 23 catego Utlook is new, The site visit team ric @but 24- was impres d with the enthusiasm of the director and staff 25 and;came t the visit with the feeling that the@progral% 6 is going to,move as rapidly as possible in the face of some 2 rather overwhelming -archaic anchors. They have a strange 3 review and management system, but it it legal and ap @ ently 4 works. The@re ion requested $1,551,251. The site visit recommended $1,050,000, and the Review Committees, $I,,010,000t 6 @@,deleting the $80#000 developmental component but dding a to -core,, 'Th to joe use ea-- @$40#000 d as t-alytic funds ii, t ntial -8 method of h ing discretionary funds is rather d heartening but it is the law Committee a opinion that the region 10 ,.,needs another year of maturity before the status of the developmental component is awarded, I could find no major 12 fault with@the description of how the development&l.component would be used f page 74 through page 79 of the application. 14 However. re could be some question about the MA ty@@of 1 5 their review process,, particularly the inexperienced majority 16 of the RAG,# 17@ it therefore, concur with the Review Comaittee's 18 recommendation to award this region $1,0.10,000 for the third 19 operati lt 1972@th ugh December 31, onal ar, rom January ro 20 1972,, and so move, 21 MR. HINES-. I second. I have nothing to add* 22 DR. P L@-. Okay. 'The motion has been made and 2 s@nded I of the Committ@e,#s recommenditi 4s on 24 the Virginia@application. Is there Council discussion?: Any 25 comments :from staff? 7 1 DRO LVERIST.- There is a kidney project. 2 DP.. DE BAKEY: I'd simply like to day that it is 3 heartening,, since I was on the first site visit to the 4 Vi inia area,, to see the change that has taken place there. rg 5 ittg quite a radical change since I WIAs on the,first site 6 visit there,, and even the changes that have taken place I 7 think they are moving into this thing,, 8 DR4 PAHLT if thpre's no further discussion, all 9 in favor of the motion, please say "Aye, 10 es 11 PAHL-. Deposed? -No sponse) 13 DRI. PAHL: The motion is dartied4 14 May we now turn to the triennial application from I I 15 3:owa with Dr. McPhedran as the principal reviewer,, Mr. 16 Milliken as backup reviewer, Mr. Zizlavsk from our staff. y 17 liar dilema in DR. MC PHEDRAN: We have a pecu 18 considering this triennial application because the excellent 19 progr coordinator and staff felt that they would be 20 embarrassed, even hampered, in pursuit of their excellent 21 program goals priorities and objectives if they were to 22 receive the 11 amount request; that is, *requested" in quotas; 23 Of- $1.147 mil icik because that includes a request for funds 24 to make projects operational which had been previously 25 approved but unfunded and which they now feel are peripheral 8 their new main objectives. 2 I think that the first sheet in the Review 3 COmittee@'s del rations which you have in the folder, the 4 first of the blue sheets,, summarizes the financial dimensions .5 of this dilema, and the Review Committed solved their problem by reco ding that the coordinator and his staff"s '$800,,GOO more or st be met and the sum f r that w bar 7 0 less. It is kind of a rough estimate but it include fu din 8 9-- 9 that's based on funding of $625,000 forrthe present year 10 that@is level funding,between the present year and the 11 upcoming one,- plus development compommt,, plus a r in 12 figure of $100,000 that I*m Afraid I don4t know exactly how 13 that was arrived ato but it is substantially lowert @thi§ 14, total paper request of $1.147 million. 15 Because this Might give an erroneous impression @16 about the p r&m@as a whole, Itd like to reiterate tha the 17 impression of site visitors vat that this was an excellent 18 Regional Medical Procrram. For example in the performance 19 category thev have apparently engaged the active interest and 20@ partidi atioh of the state medical society,, of the osteopathic p medical school and of the state medical school,, so that their 21 tive arrangements around the state really appear to be 22@ COOPera 23 first-rate without any serious exceptions we could find. 24 The process that they use,, for example, in Regional Advisory Groups,, was imaginative and thoroughly 25 1 professional one of the really, entertaining things that 2 they had done was to provide a debate forum for some of th e 3 important issues of the day in the Regional Advisory Group, 4 and this appears to have been very successful in ehcou ing 5 participation by ri of the Regional Advisory Group. 6 itis difficult to find a serious exception to this 7 this in a aisb. except that the 6vaiu t pIpr a n part 8 of it seemed to'be weak,, but that's s omethinq that they 9 shared wi many other r ional medical programs. -.on wh e, X@ :th nk hat Dr. 10 the ol i t -We nber @,g and@@his s Y! 11 staff may,i emore near y@leorrect; that is,, that, the previou I lp_ unfunded but approved projects may be more of a millstone 13 around their htdka than@,a'help. They are mostl categorical y 14 projects. I understand that there has been a great deal of; 15 pressure brought to bear on the Regional Advisory Group and lro on the core:staff @ see to it that at least one of these 17 projects was funded. Dr. Weinberg thought that he could 18 manage this could handle this, so that I guess I'm inclined 19 to support the Review Committee's final recommendation of 20 $800,000 for the first year triennium and then the other 2 figures as noted on the blue sheet. 22 so I move that we accept the Review Committee's 23 recOmmIendation, I would like to hear comments, though from 24.Dthers, from Dr., Margulies and others,, who may have views 25 iLbout this. 10 MR. MILLIXEN: I second-the motion. -2 DR. PAHL Th6 motion,has been made and seconde Mr. Milliken, would you care to make any comments? 4 MR. MILLIKEN-. Really, I agree with the doctor. -5 The only thing that I would say is that 1 think this is an @6@ unusual cooperative relationsh.ip,between VRMP and other state :7 interest rea s in@development,of their programs and is ily far down the road and not just on paper. This would be my only 9 comment. lo: DR. MARGULIES: The only commen l'Id 1 ke to mac-e Iis directed to the rather unusual circumstances here. Ideally, @12 one would like to.think that the Re ional Advisory 5roup 9 would be@in a position to discontinue its approval of what it 14 approved in an earlier eras In fact, the pressure which has 15 been placed on them,, particularly on.one project, has :)een 16 from one congressman who represents a district in the state 17 and who has enlisted the support of the speaker of the House 18 of Representatives of the state and who sent his personal represelitat and'@the speaker of the House to enter the 20 Regional'Advisorv Group meeting and'tell them that this 21 activity simply had to be funded; and it does place all o 22 then in a erribly difficult position. 23 I'm not sure, however,, that judging by the 24 frequent telephone calls we get from thP- same source, that a 25 reduction of the funding is goingito resolve their em. 1 :1 would like to think so,, but the fact remains that those who 2 are paying attention to the funding will know that there is 3 money there, that the project has been approved, that therd'6 4 no reason why:these funds can't be used for what they insist 5 they ought to'be used for. We may be buying some time with 6 this kind of arrangement. 7 There might be other ways of buttressirxg,lthe 8 coordinator and the staff and the slightly leak ade@ 9 Regional Advisory Group by any action that the Council might 10 want to take; but they are in a very tight spot and it isn't 11 evidenced in my judgment, either, that there is weakness in 12 this pro ram, but rather that the pressure which is being 13 placed -upon them is unrelenting. 14 DR. B Wellv what's wrong with it? Let's 15 get it out on the table. What's wrongr with the th ngs that 16 they wanted to do? 17 DR* MARGULIES: Well, the one that has been most 18 rtron ly pushed is one of those kinds of projects which in the 9 19 project review mechanism occasionally went the route that was 20 not expec It was a simple, familiar mechanism. The 21 Regional Advisory Group at that time, which had a little less 22 vigor, decided that the one project in particular from Red Oak 23 was professionally unsatisfactory and thought that that would -become obvious through the review process as it went national. 24@ 25 Now, unfortunately, the Review Committee and the Council were 12 1 not verv enthusiastic about it either@but they decided to go along with what assumed was the intent of the Re ional 2 3 Advisory Group and it got approved.@ So it@then became approves I 4 but unfunded to evlervbcvdv*s -consternation, and it is that particular project that this one congressman is most con- 6 cerned about and he seems to have made a@personal commitment to his constituency that that project is inct to be approved 8 and this has led,on his part to an attack on the whole Iowa 9 Rt4p with strong throats that he's going do some ing about lo, the whole business and so forth, that it@'iin't representative 11 that it is not taking care of the needs of Iowa and so on. So 12 they really are under the gun. 13 About the only alternative we might have would be 14 la very str-on ation to the Iowa RMP that they do not g recommend 15 fund those previously approved projects which appear to be 16 inconsistent with their new goals and would be a deterrent 17 rather than a support for what they are attempting to do. 18 DR. MC PHEDRAN: well, we sort of took that kind 19 of recommendation up with them when we were there. That was 20 an idea that had appealed to me,, that perhaps if we recommender 21 that funds be granted and specifically excepted projects that 22 we thought were not consonant with their new goals that this 23 would be A help. Quite to the contrary, Dr. Weinberg didn't 24 think that would@be a help at all. 25 His view was that the more appearance re s of 13 1 direction from here,, the less@ acceptable in the whole state 2@ the whole orocmam a) that if he can manage these differences ,3 himself he*ll do a good deal better than if he appears to be 4 playing the tune that we write out, 5 $o I,think maybe it's better to 'ust@do-,what he 6 says, and that is_essentially what the A6View Committee did. 7 R. It's odd that he would m ,..such a g fight ove,,r that.' 9 DR;* MC PHEDRAN-. Well,, it's a little odd that 10@ somehow we didn't catch'on to this until last ten mi@ t6s of the feedback session. You would have thought that we would 12 have been a@l@'to catch the drift of this wind before that, 13 but we didn't. 14 11 unde tand DR* MARGULIE$4 itst to make sure we a rs 15 - how the pressure is mounting, the point of attack right now 16 by the subject congressman is the coordinator,, and he is 17 saying that he is dominating and blocking. activity; and Dr. 18 Weinberg is willing to take on that responsibility and he's a 19 tough guy who knows what he's doing, so if that's his 20 recommendation I don't see why we shouldn't respect it. 21 DR. BPXNNAN.- We've got a Job for him in Michigan 22 if he's removed. 23 DR. KOMAROFF: Is there any way that the de velop- P-4 mental component could be expanded so that we would avoid a reduction in overall funds and we would still keep thelfocus 14 l@ of the@pressure on him which is apparently where he wants 2 not ourselves exemt those projects from being funded, but buttress the developmental and let him do what he wants with 3 it? 4 DR* MC PHEJ)@: Ilell, I don't know how that could This includes a recomenclation for develo'omenta 6 be done. fund said that specificall izig. I uld have ye DR. PARLT Is there further discussion? If not, 8 9 all in favor of the motion- to accept the Committeels r the Iowa ap ease say "Aye* 10 recommendations f-0 placation, pi ("Ayesti), DR. PAHL*. ooposed? 12 (NO 13 14 DR. PAHL.- The motion is carried, 15 We now turn to the anniversary section of the book 16 and review the New York Metropolitan X4P application. Dr. 17 McPhedran.-,.is principal reviewer; Dr. Millikan is backup 18 reviewer and Mr. Kline from our staff. I 19 The items requiring Council action MC PHEDRAN 20 in the New York Metropolitan anniversary request are,on this 21 white sheet, and do all the council members have that little 22 yellow appendix on theirs? I think they do. 'The items 23 requiring Council action are noted on the white sheet and the 24 stapled yellow attachment. 25 The amount of $2.235 million which is recommended 1 by the staff anniversary review panel for the third,year is 2 the same amount.that had been received by the 'New York 3 Metropolitan Regional Medical Program for their second year. it includes ten 4 @percent developmental component and I was on 5 the site@@vis4it@team that went there in December 1970 that 6 approved,developmental funding for this region. 7 Th s amount of $2.235 million is within the limit 8 that Council had previously recommended. 9 WhAt specifically requires Council action now 10 really is a request for new funds, a separate request; that ap in Project 29 a Long Island Jewish Medical Center Queen Hospital Center affiliated request; and this is to revamp a 12 13 big city out-patient department. The request is really a very 14 'good one t thitk. It's well written. it.goes over problems 15 ofbig city out-patient departments that are familiar to many 16 people here and proposes solutions for them that seem to be 17 sensible and intelligent. 18 This is essentially a project review, as it has to 19 be. It was felt by the staff anniversary review panel that 20 because of health testing equipment and health testing that 21 was proposed in this Project 29 that- it fell outside of our 22 Council limitation on multiphasic health testing, but on further discussion it appears that's not the case; that whatever 23 24 equipment is to be purchased is really part of changing the 25 whole out patient setup in this Ihospital and it really is not 16 1 an automated health testing system in the sense that we have 2 discussed it a time or two ago, 3 A series of meetings have taken place between 4 R14PS staff and the New York Metropolitan staff and they have 5 icome -up with the recommendation that's on this little yellow appendao6 h6t6. which is that Pro'ect 29 be approved 7 principle, as Dr. Brightman from New York had@.tecommended, 8@,and that a sm of money, $100,000, from RMPS would be 9 requested as new,money. This id in addition to the previously 10 suggested $2.235 million; that this $1000000 be approved- 11 @and that other funds could be got fromother sources. This 12 was actually the original intention of",the New York Metropoli- 13 tan Regional Medical@Program and they feel that they can make 14 this project go if, they have this assistAnde from RMPS. 15 So. to reiterate, the s for $2 .235 million 16 for the thi@d@"year; for $10b.000 in addition to that for the l'? Queens' project. 18 These discussions enabled staff here and staff at 19 the New York Metropolitan Regional Medical Program tb@discuss 20. together a number of things that apparently will be useful in 21 preparing their triennial application which will come to us 22 about a year from now. 23 This is another, I think, very good regional 24 medical program. They have made great strides in reorganizing @25@@ thei r relationships with the several medical@schools. They 17 1 have changed their affiliation of these medical schools 2 ]materially, especially in the last year, so that now the 3 arrangement is that the medical schools must come to the 4 Metropolitan Regional Medical Program with project proposals with specific objectives in mind,, and there is no longer going 6 to be simply the,support of somebody who is nominally RMP at 7 the@, ,several med 1 schools, and it appears that the Regional 8 Med cal Program, office has made this stick so that, for examples, @9 in some of their latest deliberations when medical schools 10 didhtt -come, in with"a project at all or didn*t come in with it 11 specified well ouqh, they didn't get -- the support was not 12 forthcoming, So it.appeari that this is really a good progam. 13 11 think it's wo: support and I move@recomendati6n, 14 of the figures which you see here and which I just went over. 15 The $2,235 million includes a ten percent developmental 16 component. 17 DR. Second the,motion. 18 DR. PAHL: The motion has been made and seconded. 19 Is there Council discussion? 20 DR. BRENNAN: I think this is the first time we've 21 beard of a project in a major metropolitan Area RMP described 29@, as ver d"organization. That's encouraging. y 900 23 t)R, PAHL: Is there further Council discussion on 24 the motion? Comments from staff? if not all in favor.of the 25 motion, please say 'Aye." IIAY 0) es 1 DR. PAHL: Opposed? 2 (No Response) 3 DR, PAHL-. The motion is carried, 4 Before we turn to the4Tennessee/mid-South anniver- 5 sary application, lfd like to have the record show that 6 Mrs. Mars was absent during the Virgi A @ication pro- 7 ceedinas and I would Also like to indicate for the record that 8 the kidney pro o#als in todav's motions have p 9 received the endorsement of Drs. Merrill and Schreiner utless 10 discussions indicate otherwise. We will be coming, of course, "i to some specific kidney proposals. I'm referring to,@he ones .@12 which are included in the recommendations we have already made on this mornihcr"s lications, 3 app i4 If we may now turn to the Tehnesset/mid-south 115 application, Mrs. Wyckoff as-principal reviewer; Mr. Milliken 16 'as backup reviewer; Mr. Reist from staff. 17@ MRS. WYCXOFF: This is a request for $2,530,,46-9 18 ifor the fifth operational year. The pro@ject exceeds Councills 19 previously approved level of funding at $2.19 million. it 20 re@res no action. 21 In this request is included the developmental @22, component Of@$ 90,1'620 and a renal disease patient care system 23 group of proj6cts totaling $266,342. 24 The staff anniversary re-view panel recommends that 25 the region@be f- @ded at the present rate of support,, namely, I 19 1 $li9O6i2O3. This does not include funds for the renal project 2 If Council approves these, then the sum recommended should be 3 added to this level. 4 The panel does not recommend approval of the 5 developmental component of $190,620. This recommendation 6 disappointed me very much because at our last site visit we 7 thought that the developmental work being done by core was not 8 only a new dynamic thrust but was within line with the national,. 9 goal and was, in many ways, the beat part of t@hei program. You 10 may remember that we encouraged Dr. Shapiro to pursue this 11 developmental work as a core activity. 12 This past year, approximately $105,,OOQ has been 13 used for this purpose, for such activities as the community 14 outreach program, the practice assistants model a,rural 15 area and the Maharry and Vanderbilt student coalition activities 16 in Appalachia. For his, we recommended, core su-p-oort o,nly and 17 suggested the r ion reapply for a developmental component 18 later. 19 The heart of the problem in making the developments 20 grant was in the fact that it is now regarded as a merit award 21 for a genuine creative ability in decision making by the PAG. aturity and balanced self- 22 Rsqrettably.'this degree of m government does not appear to@have been achieved here te@ 23 en 'ha 24 Yet. The excellent developm tal work done by this @region s 25 been the result of a:.creative core staff and director,w2'.th the 20 1 RAG in a minor role; one of the principal disadvantages being 2 the RAG's narrow representation heavily weighted with medical 3 school and-practicing physicians,, mainly from Nashville; and due to the domination of the grantee in se-lectin appointments 4 9 5 to the RAG. 6 The net result has been-that a few large projects @dead center and have not moved forw d with nat o al 7 remain on ar n 8 priorities, nor do they conformito objectives and goals focuse4 9 on health care delivery, local goals And objectives. 10 RMPS staff has madelseveral site visits and has 11 found a need to reexamine the regions goals and update them 12 lin the light of new national priorities. R@@@@AG'-,by-laws need to .be updated to be consistent with current legislation and to 14 provide better working relationships among the institutions 15 sponsoring RMP. 16 Progress has been made in the decentralization of 17 this program and the establishment of seven area advisory 18 committees which are now using hard data in their program 19 planning. The region now has ahealth data joint working 20 group with CHP and the state health department 21 RMP site visitors evidently found that the project monitoring and review was excellent. New activities@prqposed 22 -fo implementation are within the scope of the goals and 23 r. 24 objectives established at the beginning of this triennium. I think 1 concur with the staff panells recommender or 25 21 1 of the RAG of the Teftnessee/mid-South be given the hard 2 choice of funding the excellent developmental proposal within 3 a limited budget or pursuing the old course. This means 4 approving a grant of only the present current rate of 5 $1,906,203; not including the renal programl but I hope this 6 will'be the last.time we have to use this method, because 7 somehow'#' ostensibly I feel we get better mileage out of 8 judicious reward plus guidance than we do from Prolon ed 9 punishment. -Ad 10 The-' Hoc Panel on Renal Disease reported its 11 findings on Project #58 and recommended a considerably 12 reduced amount. Perhaps one of our genuine renal experts 13 'would like to, report on this and explain the reasons for these 14 recommendations. 15 DR. PAHLI Thank you, Mrs. Wyckoff. 16 DP,, SCHREINER: Which one is genuine? 17 DR. PAHL-. While welrd deciding that issue,, perhaps 18 Mr. Milliken would have some comments. 19 MR. MILLIKEN: I agree with Mrs. Wyokoff's report 20@ and again I think this.has the basis for a strong program 21 development and,l am likewise concerned with the approach to 22 them in terms of holding them back rather than @23 support on new activities. 24 DR. PAHL@. Thank you. 25 MR. MXLLIKENT I would second the motion. " ' - 11 @, @- "Ill,-,@@.. 11 , L @@ -. -i -@ @, @@ @ I @ Ipl@@@ I 22 1 DR. PAHL: The motion has been made and seconded. 2 May we have a co.mment from Dr. Schreiner or Dr. Merrill 3 relative to the kidney? 4 DR. SCHREINER: I think in general the ccrftehts 5 are good. I'm a little disturbed about one which shows the 6 fine hand of a consistent prejudice. There are a couple of 7@ individuals on our ad hoc review panel who are just@.comoletely blindly rigid about in-center dialysis. I happen to agree 9 with where the emphasis should be, and if you're going to 10 talk @ut community planning and large extension there's no 11 question about the fact that you should have home training 12 and you should be shooting for that; but 1 think it's idiotic to:-say that y Om 13 ou're going to h 0-dialyze 100 percent 14 of the peop ,@bL-:ca'use'there are many areas where the homes 15 are unsuitable And many areas where you can't have a dialys s 16 partner and many areas do require center backup. 17 In the general opinion of@the people who,have 18 worked in these,areas, when you go into the poor economic 19 areas you're probably going to have increasingly a higher 20 percentage of@people requiring center dlilvgis and the reverse 21 in the more affluent areas. 22 so@it@seems to me they have chopped out mehari-y @23 Center principally on the basis that they're hot moving @24 toward home di ysis'. if there's no motion toward home 25 ee this as a ci .ticism, but it dialysis I can s, I seems to me 23 I that to wipe them out is hurting the area,in which we want 2 to help and reflects a little bit too much rigidity I think 3 in the application of that concept. 4 DR. MERRILL: Well, Itm disturbed by a couple of 5 things. First of all, the initial report of the Ad Hoc el 6 on Renal Disease states -- this was on Septemb6r 28, 1971, 7 whereas the site visit was October 28 and they state that 8 the region -- they have a large budget request for trans- 9 plantation and intercommunication and typing and so on and@' 10 the Ad 8oc Committee states that the region has lost states 11 a transplant surgeon and the application has not dlearly' 12 indicated its desire to increase transplantation; the surgica capability is t 14 Now, the site visit of the kidney disease group 15 does' not touch on that that I can see: but they do stress 16 that the planned program.for transplantation, organ produre- 17 ment and tissue-typing is reasonable and acceptable and 18 generally re@ized; and I find it difficult to reconcile. 19 The other thing which is of some interest to me in 20 view of the@@ cussion yesterday is the fact that Component 58-B is deferred apparently because there's going to be a 22 conference by MPS and the Division of Chronic Kidney Disease 23 @Study Group on whether renal biopsies are or are not within 24 the purviewof sponsorship bv the MIP. 25 I, mys6i have a prejudice and this may only 24 1 nt@ be a personal one and I'd like to hear Dr. Schtdiner's Comm 2@ on it -- about the ultimate value of the detection of 3 bacteruria by a screening program and urinalysis. But I thinki 4 the thing that disturbs me most, while the proposal is good 5 for the transplantation and tissue-typing and computer@ 6 coordination and so on, I see no refutation of the 6f."'the 7 statement that they have lost the reg has lost its 8 transplant surgeon and the application does not@clearly 9 indicate a desire to increase transIplantation, Is there 10 anyo on staff who has any more@information on that? DR* PAHL: Bill -d 0 you have any information? 12 MR. REIST: I don't know. Mr. Anderson might know. DR. DE@EAKEY: s the t 13 where i r, sp@ant center, 14 Danville ? 15 DR.,MERPILL: Yeg. 16 DR. DE BAKEY-. I'm amazed because they' got two ve 17 or three vwole there that,l know do this,, so I have serious 18 doubts that this would hurt their ability to do,it. i9 MR.:ANDERSON: Itwas very difficult to hear you, 20 Dr..Merriii, would you repeat the question, please? 21 DR. MERRILL: My question was as follows: On the 22' second page of the ad hoc panel survey and summary, the 23 statement is made that the region has lost its transplant 24 surgeon and application does not clearly indicate a desire to 25 increase transplantation; the surgical capabilitylis thin. I 25 1 see no mention of the fact that this has been taken into 2 consideration by the site visit people. Maybe Dr. DeBakey 3 can enlighten me. Is Bill Scott interested in transplantation? 4 DR* DE BAKEY: Very much so, and I know of at 5 least three of the surgeons on his staff who are interested 6 in it and are,doing it. That's why I find it difficult to understand 8 DR. MERRILL: I think that would answer that 9 question.- 101-1 MR4 ANDERSON: Well, we met with bt. Scott Or the site visilt-team did -- and Dr. Scott assured us that'he 12 was,,definitely terested in transplantation@and is now actively tation 13 ting- for a full-time transplan our on. 14 MRS. CKOFF: You know, I hate@to raise this 15 ilisue, but it does seem to me that where you have two medical 6 @centers as near s Memphis and Nashville,, why you have to have 171, two underused systems of transplantation when you might have 18 one good one. I just,can't understand it. Do we have some 19 way to'examine@the strength of these things and where the 20 ases are ardless of the region? @21 DR. rW,.- We h- ave been ma ing an effort, as 22 you remember in e past meetings of Co=cil,,@to t to 23 identify on ageographic basis the relative need fora 24 transplant centers whidh is based upon local resources and P-5 DO%>Ul ti r rements@and potential ne a ed which@can be fairly I . I 26 1 well identified for dialysis and transplants; and whether this 2 'has been applied in the review process -- maybe again, Mr. 3 Anderson, you could@.respond to that particular question. Thel 4 issue was whether this represents an excessive development 5 of capacity when there are medical centers in Memphis and 6 in Nashville which would presumably serve the same population. 7' MR. ANDERSON: Well,, geographically, I don't think 8 this would be true, and the transplantation capability in 9 lmemphis is extremely limited where s Nashville has really 10 established themselves as a trans lant center in the,Mid-South p 11 @,and they have been very actively in a transplant effort for a 12 number of s. This would help theta to perpetuate their 13 'complete,cc)mpreh6nsive program. 14 DR CANNONT. What was that about the Memphis Ca@ilitv being limited? He said that the capabilities in 16 Memphis were extremely limited and I just wanted to know if 17 that is a true statement because I -- 18 MR. ANDTRSON: maybe my choice of words is not a 19 very good one. They haven't been too active in transplant. 20 DR. CMNON: Because they haven't had funds. 21 MR. ANDERSON: Yes, Sir. 22 DR. MERRILL: Does momphit.have a computer to 23 organize their organ procurement and typing? 24 DR* CANNON: Dr. Merrill,, I really aon*t know. All 95@ I know is that Dr. Britt and Dr. Hatches has'got a program 27 they've been working on for some time but it's limited in 2 funding. 3 DR* PAHL: Is there further discustion? 4 DR. EMIST: It would seem to@me that this might 5 be a time for us to,again bring up the possibility of 910 6 money for the-'s-outheastern area of the country working 7 together on some of these projects and it would p babl ro y save 8 RMPS a considerable@amount of money and get a better uaiit Y, 9 of care. it seems to be a natural with all the talent, wit4 io McDonald in Now Orleans and Hum in Pichmond and the oplai @@pe at are scattered around this area,, would have a ball I think 12, if they could aet together and cooperate. DR@@t)z@BAKEY. Well, there it an ffort being made to do th le mid-south and doei and southwest r'n 15 area in an effort to provide coordinated programs, particularly 16 @u in terms of.@ tilizing the computer for donors and that sort of l@7 thing* theregs considerable effort 1 know in our part Of e untry to do this,, so I think a little push@@on the part of 19 helping then do' is would be good. 20 Another comment I would like,to make about this, as 21 far as ,@surgicAl capability for transplant, there's no lack of 22 surgical capability. the problem lies primarily in finding 23 the funds to support a good center organization where you have 24@ all of the resources available. A kidney transplant program the surgical standpoint becomes completely inadequate 28 1 unless it has all the total resources, particularly in terms 2 of kidney dialysis and support of immunologists and others to 3 create the total center. 4 As far aa@the technical aspects of it from the 5 surgical standpoint, that really constitutes the easiest 6 component of the whole thing and there's no lack of trained 7, personnel for this purpose. it's putting-together the total 8 organization and,the.supporting organization, and this 9 requires fuftdin of the center. Prequdntly it's not 9 10 available to the center's resources and-this is the main 11 dete nt,to@ rovidinq the best kind of organization. 12 I know in our own setup,, where we have been doing 13 lkidney transplants for along time,, 10 orl,12 years now, and @l continuously doing it, we have to scratch toget the funds to 15 support the total activity. 16 DR. MARGULIES; I think that the idea of the 910 1'7 mechanism is@most appropriate. The Southeast coordinators 18 have been meeting together to develoo:a common approach to 19 kidney problems and,, as Dr. DeBakey indicated, th is not 20 confined to the southeast area. 21 We wi 1, in the process of developih the new kind 9 22 of protocol which:we described yesterday, lay emphasis on the 23 utilization of the ilO approach because it provides a mechanism 24 for getting around exactly the issue which you have r sed, 25 Mrs. Wvckoff@, And 1 think we should promote the idea now rather 29 1 than wait for any further developments. 2 DR.,.SCHREINER: I wonder if Mr. Anderson could put -C" 3 a dollar value on it.--I can't break it down from So 4 which is the dialysis c ponent, is approved in general at OM- 5 reduced funding:; but I can't break down the figures. I think 6- you ought to@,put that back in and recommend to them that ..iey 7 6xpand-fbr a4@.four-bed unit and that they come back in@with a lemental a lication and try to initiate A home-training -SUPP pp 9 an adjunct to that. ,program a, 10 llowing your philosophy, I think it's be ter to reward them. If they don't have a nurse that two-bed u t 12 may be@-wioed out. 3 @DR. PAHL: Mr. Anderson, can you place a dollar 14 figure on thit?. 15 MR* ANDERSON: it's in the neighborhood of $1@0,000. 16 MRS. WYCKOFF: So $58.000 would be t68;000, Do 17 you need a rption on this to approve the sum of $176oOO0for 18 the renal Proiect? 19 DR. PAHL: Wellt the Chair understands that the 20 motion on the Tehnessee/Mid-South application is to approve 21 the recommender o ,_g staff anniversary review i ns 22 to(Itether with the recomendations of the technical kidney site vi*it team,, to@which,is added $10.0 00 for section:58-7C of the 24 kidney propos 25 DR* @@INER: For Meharry 30 MRS. WYCKOFF: For Meharry. DR. PAHL: for meharry. e tion 2 If that is th mo 3 which has already been seconded, may I ask if there is furtheri 4 Council discussions 5 MR. HINES: Question. 6 DR. PAHL: All in favor of the motion, please say 7@. ItAye,u DR. PAHL: Opposed? 9 (No Response) 10 -DR. PAHL: The,motion is carri 11 We now turn Aghington askA anniversary 12 application. Dr. Konaroff is the Princi al reviewer and 13 Mrs. mars is back reviewer and Mr. Moore-from our staff. UP 14 Dr. WAtkins, I apologize for not noting your 15 absence from the room during the New York Metropolitan review procedure. 17- DRO KOMAROPF-. This region is currently funded at a 18 level of $1.45 million. The Council has already approved the 'level for next year of $1.96 million. The commitment that the 20 region understands it has from the director for next year is 21 $1.51 million, and it is requesting somewhat more than that 22 'but somewhat less than the Council approved level, $1.68 milli4)n. 23 The main@reason that the.region is requesting 24 additional funds and the reason that the staff anniversary 25 review panel has agreed with that request is that they have 31 1 five new activities and they wish to expand their developmental 2 1component. 3 1 Since the Council last looked at this region there's been several changes that are encouraging. The 4 5 organizational structure has changed so that five associate 6 coordinators for each of their five key program areas ,,ave 7 been designated and there are five corres dviso@ 'ponding a 8 councils that work closely with the core staff in,these-areas. c -c! They 9 Their general goal statement has been de ategorize lo@ have moved further away from a primary emphasis on@@@wntin'uing 11 education and into newer areas, some of which we've already 12 heard about yesterday and I'll briefly allude to. 13 Rhetortcallyt they are pointing mot6 towards the 14 'delivery of care to:the poor, development o.f new types of 15 paramedical personnel,, Is reeninct and prevention activities, 16 a public health education activities,, increasing the rur 1/urban 17 linkages which have already characterized the region,, the 18 stimulatibn@of HMOs, the Stimulation of area health education 19 @ers which ey have an ideal opportunity to promote as par can t 20 of the University of Washington peri pheralization medical 21 school program called WAMI,, which has a kind of zing to that 22 achronym that's,,uncharacteriatic of most,of the achronyms we 23 deal with, 24 They're also encouragino.m6di@cal audit Proarams in 25 several private practice settings. They have the satellite 32 nds f medical information to remote 1 Itransmission of various ki 0 2 areas, primarily in Alaska; and their activ'tieswith the 3 proposed Northwest Cancer Center we talked about yesterday. tive agenda that has impressed everyone So this is a very,attrac 5 who knows the region and who has worked with it from staff. 6 They also have@an extremely vigorous advisory 7 council under the leadership of Mr.@O n who is on our 8 Council,, and this has been a major 'change since our last 9 review. 10 Lastly,, their core management staff has developed 11 what they call the programmatic approach in which various 12 program goals and objectives are outlined specifically and 13 budgetary allocations are made to each one. This looks-on 14 paper as if it should allow them a very t ht and effective ig 15, management of the program. 16 Their current request includes support for seven 17 projects which already-we have approved; the three small 18 projects for which they request an additional year's funding 19 b ut which will terminate after .that year; and for five new 20 projects, one of which is a vital statistics program to 21 coordinate the various kidney Activitidg@already funded. One 22 proposes to upgrade comprehensive care in two small rural 23 Alaskan villages. a third to develop a comprehensive care an: Indian population in Seattle; the fourth 24 system for an urb 25 to expand the role of the stroke nurse specialist which has 1 been developed in an, already-funded project; and last, to 2 ]support activities of the Allied HeAlth Association in Alaska 3 to expand and train new kinds of paramedical personne or a 4 region which cannot likely look forward to many new physicians 5@- The region appears to be very well run. The 6 advisory group is extraordinary, and the new activities seem 7 to fit with@the region's honest priorities and the national 8 priorities. 9 Therefore, I concur with the recommendation that we 10 recommend to the direc t of $1.68 million, 11 including a developmental award for $110,000, and including 12 support for all five new project proposals. 13 The one aspect of their request which I think we 14 cannot approve is support beyond the next year for project 15@ number five which is their large continuing education medical 16 film and television program. I think Council should look at 17 that project in the context of the triennial application ch 18@ is expected next veary but otherwise, I concur with the 19 recommendations of the staff anniversary panel. 20 DP.. U, PAHL. Th@ yo Dr Komaroff. Mrs. Mars. 21 MRS. MAPS: I certainly concur with the recommen- 22@ dations, but I think all their continuing education programs are especially excellent. The onl thing that did occur to 23 y 24 me in going through the program is the fact that there doesn't 25 seem to be very many programs targeted toward the minority 34 1 there's a very large population of groups and I believe that 2 @Eskimos and Indiana. The last project, the Allied Health one, 3 certainly is targeted in that degree but also, in going 4 through their RAG there doesn't seem to be any representation 5 for minority groups at all. I don't know just what the 6 figures are on the Indian and Eskimo group in population. 7 Does the staff know? MRS. RESNICK: 55,000 in the Alaskan native$. 9 DR. KOMAROFF: Sik of the 40 members@of their @io advisory group are designated as minorities, about 12 percent of the total membership. MRS. MARS: They're de as more or. 12 si0hated @less L ti minority representatives rather than actually minorities. Surely, there must be one educated Indian or one educated 15 Eskimo that could speak for themselves as to their needs, I 16 would think,, on the RAG. I felt this was really a very 17 @seriou-s lack in the programing and something should :>e done 18 about it. So I would like to see a directive to that added 19 to the recommendation. 20 Another.thing that came to my mind was that there 21 seems to be a concentration of the projects being carried out 22 in Seattle rather than Spokane. There are some certainly 23 headquartered there, but all the activity seems to be centered 24 in Seattle@ 6rhapt because of and I wondered why this was. P 25 medical facilities, or what is the reason; and also, a good 35 1 many of the RAG are mostly concentrated from Seattle. 2 So those were my criticisms more or less in going 3 through the program. It seems that there could be a few more 4 innovative programs started. It looks to me as: though they 5 need more Airplane service in carrying but health programs and 6 this t of thing. I think it's a very constructive pro ram, ype 7 very sound program' but I@'ust didn'4t think it was terribly 8 innovative. So that's my criticism however, I do concur 9 with the recomm 10 DR. PAHL: Thank you.-Mrs. Mars. Are there comment., 11 'from Counpil or staff? 12 DR. BRENNAN,." ,Regarding mrs.,Mars' point on 13 representati@on, I think it certainly is desirable that there @14 be le who can speak with authority about the needs of the peop 15 orities; but sometimes the best that you can do is get a 16 missionary @or someone of that sort who"s working with the e ry re is e h identified with them if the; @isn't 18'. terest or if there's a lack of division amonast the 19 ,,minority groups, which has happened sometimes, so that@yo 20 canit select one representative without getting other groups 21 angry. 22 So I wonder whether it is as unrepresentative as 23@ it looks on'tutface or whether there are people who really 4o speak out in an@@informed and concerned w for the@@in resti; 24 ay 25 of the minority groups in Alaska, 36 MRS. IIYCKOFF: I think one of their problems has 2 ,been the fact that distance of that region is as big as 3 one-third of the whole United States. 4 MRS. MARS: Exactly. That's why I say I think therB 5 should be more programming targeted towakd@@'servicing', such as airplane services and this type of thing, 7 DR. MARGULIES: In their defense, let me point out 8 what contributions Washington/Alaska has had to the develop- 9 mett of WAMI; and incidentally, Tony, I wonder if you have any 0 feelings about the impact of WAMI on W OIE. (Laughter) DR. MARGULIES: The primary contribution of that 13 program to the development of WAMI is completely relevant to @4 thelissues you just raised,, Mrs. Mars, What they have 15 designed@and: r@which they have gained the support of the 16 legislatures of All of the states involved, the@governors.@the@ 17 leading medical people@ and so on, is a me od o'. n 18 total medical educational system which is based upon@prognostii-. 19 health needs over the next few decades derived frcm',democtraphi(-, 20 information, extending to the greatest periphery of the Alaska 21 area, taking into account the needs of the Eskim6si looking at 22@ the problems of Montana and Idaho as@w6ll as Waihin ton and 9 23@ Alaska, was a inative,kind of a concept. 24@@ 'This has attracted a $1 ant from the illion gr 25 C nwealth Fund to extend this activity. What they expect 37 to be able to do is place educational activities in areas of 2 service with the hope that people who learn to manage patient 3 care problems in a given environment will remain there an 4 that this will develop local competence which will be fostered over a period of t@e. 6 The distances are extreme and yet it Always 7 surprises me when I talk with people up there how frequently 8 they are in Alaska,,,,for example, and how much they deal with 9 the problems which are thdre. They haven't done all we would 10 like to have them do,, but they are not unaware of these kinds of issues. 12 3: think what they're trying to build is more 13 profound Iand@something which will influence events for a long period of time through the so-called WAMI activity 15 MRS. MARS: Thank you. 16 MPIS. WYCKO FF-. Could 1Ask a Iquestion about the 17 how it'-$ being used.in the extent of Medex program and 7 18 RMP prograkm?, 19 -DR.-KOMAROFF: They don't speak to it in-the 20 application., .1 ink they have Medex personnel in 14 physicians 21 offices already since the last time I read about that Modex 22 program, but there's no information on it in the appl cat 23 and I have never been to the re4ion, 24 DR* MARGULIES-. The Medex program is separately 25 @funded by 'R D but the working relationships are.ext ly 38 1 !close there. 2 1 MRS. WYCKOFF: This is why I was wondering if we 3 were somehow involved in placing them or in any kind of 4 relationship in the outposts. 5- DR. KOMAROFF: Yes. 6 Then you have all these Aleutst too? MRS. many of them there are,, that seem to be. 7 1 don't know how 8 absolutely ignored completely. -discussions y 9 DR. PAUL. is there further !D@ Counci,@l ded to acce the 10 or staff? The motion@has b -TM 11 recommendations of the qtaff annive 's@ review panel on@tht 12 Washington/Alatka applicati f there's n further dis- on. I 0 13 ion,, all favor of the motion "Aye.it please say 14 ("AIMS 15 DR. PAHL-. opposed? 16 (No Response),, 1.7 DR. PAHL-. The motion is carried.@ 18 The record will show that Mr. Ocrden,was.@absent 19 the room during these proceedings. 201, May we now turn to the last of the anniversar y 2 r'st is principal applications, from Wast@Virginia. Dr. Eve i 2@ 1 reviewer,- Dr. watk -s,, backup reviewer; mrs4 Faatz from our 2,: Z3 24 DR* EVERISTT This is an anniversary application 25 bofore,tri m concerns oni the region's third y 39 1 mechanism is particularly operational year. The new rev2.ew 2 applicable and successful forthis region. The staff review 3 and the staff anniversary review panel are in almost total 4 agreement. They differ by $46,771. They both disapprove a 5 developmental component but the staff review would allow the 6 $46,,771 to remain in the approved amount as a S'uo-olement,to 7 core. The staff anniversary review panel refuse to play s @8 The total amount recommended to the director was $9,29,8100 and 9 this amount has been accepted by him and is presented to 10 Council for con 'irmation. The developmental component would 11 have been well olaced in the five-area liaison offices and 12 probably would have,beon spent@in small amounts of $@1,5-00 or ut 4pprov cu ve Comm ttee d 13 less witho al by the L-xe ti i an 14 advisory group, two paragraphs describing the'spendi 9 15@ of this money are vague, I agree that the developmental 16 component can:well await the triennial application,next year. 17 ld call 'We I wou to Councills atten 2.on two of St 18 V30.rqinials projects that are unique. one is the licopter 19 feasibility@emargency study in Regional Me4ical Services6 20 This -project could well supply information applicable to many 21 rural sections of the country. The project has been tO=inatel, 22 except for a $3OiOoO request for a part of that project. I 23 sincerely hope the staff will see fit to encourage recon- 24, sideration of this project. 25 The second project of interest is the ohvsicians self-audit podr review. This project has been slow'in getting 40 started, and there have been no auditg to date. Howeveri the plan is sound and c-uld well be the prototype for a future 3 system of quality control and continuing education of 4 physicians, 5 There's also-a vignette@.,,on a@project that will be funded with cooperation with lawyers in ch@ing the state 7 law in some areas that the vignettes found interesting; I 8 didn't find it particularly interesting. 9 But I move we accept the recommendation of the 10-@ director, approving $929,910 for t e h year. As an aside, for f uture reference,, council should 12 i 'recognize that West Virginia is a poor state with a pa ty ol@ .-super s ocialists in all fields. Like Arkansas, th reall p ey y 14, can't afford a med cal school,- but they@do,, and they try, and 15 they are effective. Staffing will always be a problem since 16 Mor antown is is dlAted from the rest of the world.@ he West Vir' inii Re ional@Medicdl Program wil need your,help to ake 4 difference in that rugaed state. 19 DRO PA'HL: Thank you, Dr. tverist. Pr. Watkins? 20 DR. WATKINS: I conau yi r Dr. tvekist's state- 21 ment . 22 DR. PAHL: Is there Council discussion? 23 DP,. DE BAKEY,: Let me just say that having spent rgantown, 24' some time in Mo West Virginia School of Mddioin I 25 @really think they deserve the@greatest amount of help.; It's 41 1 very difficult situation there to provide the kind of 2 resources that are neededo and yet they make a very strong 3 effort to do so and I've never seen a place that has better 4 spirit among their personnel in their efforts to try to help"l 5 and particularly the medical school't faculty in their effort 6 to try to provide community support in taking card of the 7 needs of that region which are difficult to meet'. 8 Their funding is quite limited and they've always 9 developed a very good spirit about the Regional Medical 10 Program, and :E must say that they deserve all the help that 11 we can give them. 12 DR. PAHL: Thank you, Dr. DeBakey. Is there 13 further discussion from staff or Countil? If not, the ChAir 14 understands that there is a motion made and seconded by the 15@ principal and backup reviewers to accept the recommendations 16 of the panel on the WesIt Virginia application. If the 'Is no 17 further di si I'd like the question of all those in scus 18 Ifavorl please say "Aye." 19 (*Ayes 20 DR* PAHL: Opposed? 21 (No Re@nse) 22 DR. PAHL: The motion is carried. 23 may we now turn to the last Ap e ,placation in th book 94 under Spedial Action, which is an ap .plitati6n from Missouri, 25 and we have asked Dr. Komaroff to be the principal reviewer; 42 Dr4 McPh6dran to be the b ckup r Viewer; Miss Houseal from oui a e 2 staff. 3 DR. KOMAROFF: This is a request for a small mnoun 4 of money that has,an importance beyond that sum. Because of 5 the new members of the Council may not be familiar with'the 6 saqA of this Regional iledical Program, particularly its 7 computer efforts, let me just briefly refresh our minds, on the 8 history. 9 From 1967 to 170, the tegion,under the leadership 10 of Dr. Wilson, established eight computer,@.bio,en 'inee ng projects which were funded at a level of approximate y, 12 $2 million eachlyear. Site visits in October of 196t' and 13 1969 by computer experts and others raised serious about much 14 of this effort but recognized the@potential of some Of it. 15 Although the original plan called for a three-year 16 effort the Council at that point, two years ago agreed to 17 an additional ar's support at a level of $1 milli6ni@ 18 guaranteeing@no support beyond July 171 but not foreclosing 19 the-possibility of-support either. @20 Another site visit in March of this year felt that 21 the maximum tupport@fot@a fifth year could be justified 22@ purely on technical bases and not on any other overall 23 considerations,, would be $600,000. The Councilt acting ast 24 g. reduced this level to $300 roug sprin 01000 hly. $15 00 o 25 that mon for@the Bass project which is at issue today. ey was 43 1 I want to point out that that project requested only@$150,000 2 and was the only part of the Missouri application to be 3 funded -- approved and funded at the level requested. All 4 other parts of the application were reduced. 5 WhAt is the Bass,project? Well, it.is an attempt 6 to move out @a@rural Practitioner's office, a sold 7 practitioner, several of 'the computer efforts which had been 8 developed individually over the last three to four years. 9 These included an automated history project and computerized 10 :EKG inte tati@'n project, a biomedical information project which allows for the instant or relatively rapid retrieval 12 of information for A practitioner, and a radiol64v interpre- tation project and a multiphasic screening project which 13 14 really is a blood chem3'.stry screening project. 15 Now, the request for a special Action before you 16 today results from a series of unusual actions taken by the 17 region and I think these raise in themselves some serious @18 procedural issues. 19 First of all the region appears to have made a 20 delibetate'decision at the time of receiving this award last 21 July to overspend beyond its $150,006 budget in the 12-month 2 Per3'.od, ey did not let the RMPS staff know ab ut t s 23 decision, however@,, until November or October of this year, at 24 which point th y@@sa d. "We'll be out of money in six months e 25 and we'll heed $150,000 more.' 44 1 They then sent in a request in which they did not 2 state how the money that had been spent in six months had 3 been spent other than to say "Improvements beyond those 4 anticipated initially had been done,," and they gave very few details as to how the additional $150,000 requested would be 6 spent. 7 There was an "other" item on the budget, a line 8 item for $80,000 for "other,," which was obviously computer 9 and information transmission charges which was really not 10 itemized, There are also some more fundamental problems 12 beyond the procedural on6g* There has been no evaluation of J.3 the project goals of improving,quality or efficiency and:none 4- is yet contemplated. Fttthermore, none of the component 15 projects which have been ongoing now for four and a half yearE 16 have been evaluated,and there is nIo -- we asked the region 17 within the la t few days.whether there was any ongoing 18 evaluation pro eAo@@and@they indicated that there was not. 19 Furthe the-supolemental rmore, thek6ls ho.sense in 20 request here as to their view of the lative worth of these 21 five subcompo ent;lpro]ects. They don't@@@ dAl with the issue raised by Council last time of whethek-loutting all of this 23 machinery into solo practitioher's okfi@ce,in a rural area 24 could ever become cost-effective and whether that's the kind 25 of setting in which the,experiment should be tried,- and they 45 1 don't discuss in their formal application any plans for how 2 they would continue this effort or in what kind of setting 3 next year. They have subsequently responded to our questions @4 by indicating-several possibilities toward other rural 5 settings, one multispecialty practice in Columbia, but none 6 of these are developed beyond a sentence r two description. 0 7 An@er complicating factor has been that Dr., Bass, 8 the physician in whose office these activities are located, 9 had a second.myocirdial itfarction this fall and has b66h out 10 of practice and will be until the fi:rst-of the year. Three 11 physicians have taken over oh an interim basis And are using to some des e the component pr6j6ct$.@ Now, there were some encouraging signs that was 13 IA There is a evident in the responses to our questions oreliminary market survey being done oh the information system 16 which has been called Fact Bank which indicates there'sa 17 high level of interest among physiciahg in the state and that this might become stlf-tupporting in a year or two. e EKG effort also appears to be attracting national recognition$ 20, p,, and its leader Dr. RtssOll particularly in Sanazaro's sho 21@ Sandberg,, is outstanding; but it still has hot solved the 22 problems of recognizing arkhythmias,, particularly P waves; 23 still has not solved the problem of@r4616ocrnizihq 44 io 24 changes in ST segments @:do res io vations. s ns and ble 25 DR. BRENNAN: What has it solved? 4 1 DR. KOMA.ROFF: Dr. Bass usep.,,@S-,,.l t every 2 computerized interpretation is concurrently interpreted by a 3 cardiologist and this joint interpretation will apparently 4 continue for the next year or two. 5 The radiology project has@proved its worth as an 6 in hospital aid to a radiologist, but its meaning in a 71 setting of a rural general practitionerlt office is not 8 apparent to me. 9 Therefore, my recommendation is that Council 10 this request for additional fundincr.@but not deny the region 11 the option of rebudgeting.within its overall $2 million grant 12 into this activity to keep it alive if the region really 13. believes that this is what it wants to do. 14 Before defending-this recommendation let me 15 raise several problems which could arise in taking this 16 action. The firsIt is, that the regions says it we do so that 17 the whole effort will die and that $7 million of activities 'it will have gone down the drain. will much-of,@ 19 The other possible objection is that,our,action 20 might run counter to the interest in healt tec no gy 21 expressed yesterday in which I think all of us have a great 22 deal of hope. Nevertheless, I think,the acquiescing to the 23, unusual procedures that result in this request for special 24@ action;and the more fundamental questions that I have dis- 25@ cussed,, make,it reasonable to deny the request; and it's my 47 1 personal belief, from having seen the region make similar 2 statements in the past as to what would happen if funding 3 requests were denied or reduced, is that in fact the effort 4 will continue as the other efforts for which they requested -5 $1 million this year,@,have continued despite a $20oiOOO budq6t. 6 possibility that perhaps this whole 7 effort.has -now reached a stage where it could be more 8' reasonably supported4on a contract rather than a grant bas3'.Sl 9 so that tighter control of the activity could be intti ated. 9 10 A contract @'fr-om where, I do not know; perhaps from RMP or f elsewhere. @'@ere's@obviously a g eat deal of mone down the -2 r y 12 pike:for this kind of activity and Missouri has a great deal 13 of competence in the area. 14 DR. PAUL: Thank you, Dr. Komaroff. Dr. McPhadran? 15' DA. MC PHEDRAN: I just emphatically concur. DR. KOMAROPF: That'A a motion. 17 DR. CANNON: Tony, you mentioned several times that 18-- the information was absolutely lacking or not displayed or 19 'something. Are we sure that we've made theeffort, our RMPS 20 staff has made the effort to see that any lack of information 21 is being brought forth? I just want to make sure because if 22 this moves up the line there might be some things well, 23 repercussions. 24 DR. KOMAROFF: @I had an,opportunity to look at this 25 material a week and a half ago and Dt4 McPhedtah did, too, and 48 1 we Asked Donna Houseal, who was out in Missouri the last five 2 days, to raise a whole host of questions. It took about an 3 hour to transmit them over the telephone. We have back a 4 series of replies, much of which I've incorporated into my comments but none of which answers the fundamental questions 6 which were posed through@Miss Hbuseal. 7 MISS HOUSEAL: Dr. Cannon,, an extensive advice 8 letter@went out to,this region after last Council review. 9 I've had continuing conversations with this region since then 10 about the points raised at that tim6o so th6re's been a 11 continuing dialogue with th' almost weekly a is region bout these 12 activities. They are aware of our concerns. 13 DR. PAHL: Is there further discussion? 14 DR. BRENNAN: An interesting sidelight on this, 15 there's a fellow by the name of Jack something or other who is 16 In Vern Wilson's office and he's in charge of biomedical 17 technolo ical development and that group and hela,written a 9 18 number of books on the subject. 19 DR. PAHL: Dr. Jack Brown? 20 DR. BRENNAN: Yeg, Dr. lack Brown. H6 was out to 21 @the Engineerincr Society in Detroit last week addressing their 22 biomedical committee, and to hear Jack talk,, it appeared@that@ 23 there was great feeling on the part of everyone down here t At 24 schemes like the Bass project had a great deal of support and 25 that much was to be looked for from them. 49 I took occasion to ask him a few questions about 2 the impact of this project at that meeting, but I would say 3 that itis clear to me that there are in various quarters 4 great enthusiasm for this type of eff r 5 Now, I hesitated, though,, to see RMP so much 6 identified with what I would call an instrument-determined 7 type of activity in a public way, It made the papers a 8 over Detroit and it's going to complicate our live n o en 9 in the 1*IP in 14ichigan. I note that this is described as 10 favorable publicity, this project, if someone puts some 11 quotation marks around it; and I would, for one, like to see 12 a little downplaying of this until we're sure that wetx-e not 13 ion in expenditures all going to be embarrassed by what $7 mill I- A has yielded. 15 DR. PAHL*. Thank you, Dr. Brennan. Is there 16 further discussion? 17 m@ WYCKOFF: What's the early history of the 18 planning of is in terms of reporting svgtems and how did it 19 t into this co di ion? ge 20, DR. KOMAROFF: Well,, at an early stage there arO 2 people on the Council that can Answer this' much better 22 in the early stage in M4P's history, there was a good deal of 23 money to spend and there was a great deal of magnetism and 24 enthusiasm on the part of Dr. Wilson in the area of health R5 technoilo n which I think everyone shared,, and he@said he gy 50 could get and, in fact, he did get a verv large and very 2- ambitious effort off the ground in short order that has -3 produced some very nice results. 4 MRS. WYCKOFF: What about the reporting and t-te 5 evaluating and the reviewing and the record of annual 6 accomplishments@on this Particular thing? You,.Iseem to have 7 had correspondence just recently about it and-I wondered what 8 ,happened a year ago and two years ago? 9 DR. KOMAROFF: Well, we site.visite'd three or four 10 times during this period and the questions that I have alludes 11 to were raised At each point, and the decision@was made that 12 this was a new area and there was promise to,,p.rotect and that 13 certain investments should be continued. it phased down 14 substantially after the third year; first 1 million and 15 then, closet to half a million dollars; but there was constant 16 feedback I think -- Miss Houseal can speak to that -- between 17 the Division and the region during this period. 18 DR. PAHL: Donna,, may we have Dr. Millikan's 19 'comments? T think he was trying to get a statement in. 20 DR. IIILLIKM: This is in partial response to your 21 question, Florence. When this idea was brought to the Council 22 unde the@word originally, the decision to fund it wag made r 23 "experiment," and it was decided that the funding of this 24 computer research or research concerning computer akpp-licabil I-.y 25 to medical practice and medical service should not be construed 51 1 as a precedent for this Council at all, but that we wanted to 2 see what an organization could do 'With this kind of an 3 experiment; and several of you will recall that we funded a 4 number of different kinds of experiments. There was one -having to do with.ihtensive cardiac date unit linkage for 6 instan!De@,,Iin which we bought them the computer, etc.,, as an 7 experiment. 8 't was decided that In the original grant action, 1 9 te approximately thr-eey -af r there should be 10 full evaluation of the results of this experiment and the iect@site V@s'its, as I understand them I haven't been on Pro 12 L@' of@them --'but as ave a any I understand them,, h ddressed 13 themselves to that kind of evaluation; and it simply.was 14@ determined that the original described possibilities of the 15 experiment had not been fulfilled. 16 So I don't think there's any great chagrin about@ 17 that because as we understood the whole issue at that point ir 18 time, it was an honest use of the word "experiment." In other 19 words the results of it were not predetermined and we didnot 20 know what they would be able to accomplish in that experiment 21 y more than in some of theothers,that have@gone on. There an 22 have been a series of these kinds of thintrs take@@'place, my 23 own institution and Lockheed conducted one where millions of 24 dollars have been spent and it has not come off either, I 25 might say, in terms of producing a result in terms of an 52 automated history,, automated record'system,, etc., etc. 2 So that's a little bit of Council background. 3 DR. DE BAKEY: May I ask how much total mo ney 4 do you have any idea of how much total money RMP has spent in 5 all of these,computer projects that we did approve and then 6 called a halt on in terms of evaluation? 7 DR. MARGULIES: We gathered some data ori that. Ed, 8 do you recall offhand how much we spdnt? It's a very signifi- 9 cant sum of money. ull it to other 10 DR. DE BAKEY-. The re wonderin if RMP hasn't invested enough money how to be able 9 12 to say,, well, this justifies a thorough review in trying to 13 determine just what'has been accomplidhed,,by it. The reason 14 1 say this is because I know that there is a strong interest 15 on the part of Jack Brown and people in Vern Wilton's office 16 to move this program ahead and invest more money in the @17 clinical application of computer engineering for health-relatel 18@ activities, 19 Having some interest in this area and having 20 actually a research program of my own, which is a research 21 progr really designed to try and determine just how best to 22, apply this technology,, I have been little concerned with 23 this effort to push ahead in the ap I I ,pl'cation of th's requiring 24@ huge sums of money and yet with no good evid Al ence that I have 25 seen anyway -- and certainly in our own program that I've been 53 able to see -- for justifying that expenditure of funds. 2 Now,, it seems to me that the Regional Medical 3 Program has made a serious effort to experiment in this 4 field. We set up a program. lie had a policy about it. We said we're not going to spend any more money in this area 6 until we find out just what can be accomplished. It seems tol@- 7 dpoint of the Regional medical P tam me, not only from a stan 8 but also from the standpoint of the total federal funds at 9 are being expend6d,in this area, it would serve ausefu 10 purpose to have a a studv. a special o the funds the Regional Medical Program of what has come out 12 that we've put into this area. DP,. MARGULIES: Yesterday we described briefly two 13 14 efforts which are now underway to look at two major a pects 15 of it. one of them is ECG monitoring, and we have a study 16 which we'll be able to report to the Council next time; and 17 the other is on so-talled multiohasic health testing which is 18 also undergoing study and we'll be tdoortihcj back to th-e@ Coundil. But@thege are only parts of what welrd talking 20 about. 21 DR. @DE@ @BAKEY: These are rather special-parts 22 and they@can perhaps be evaluated specifically -and sepAratel-V, 23 but I'm talking about the broadly designed type of program 24 such as the one in Missouri, which is a very ood example, 9 25 and a few others, in which the technology is designed to, in 54 r to make more efficient the sort of diagnosis sense, replace o and management of disease and illnesses and computerized 3 history, phvsical examination and the diagnosis, going 6 'even 4 to treatment. 5 There has been a tremendous amount of money that's 6 already been put into this particularly in terms of even 7 computerized or closing of loops, to-called,,@in treatment that 8@@ hasn't panned out at all. it seems to me we have spent enoug 9 money to be able now to justify spending a little more money 10: to do a really thorough study of this. Enough time has 11 oh for over three years now. It seems elapsed, This has gone 12 ---and this is re Ily to me that the Council shouldrequest a 13 what I. am aski if we haven't reached the point where we ng can request such a StU And I ",.don It much care how 15 the Director designs or d6veloos the study. I think Iwould 16 o you, but I think it would be very leave this entirely upt 17 worthwhile to do. 18 DR. BRENNAN-. It seems to me that I would certainly 19 like to second%the motion of Dr. DeBakey, and in this s6nse: 20 1 think we did look at another areas that has been consuming 21 a large part of our investment,and had been under operation 22@ @for a while.. We took a tack of convening a conference-on 23 multiphaoic screening and we dame out with a review of the 24@ problem and-.brought it back to Council. 25 I think that it's high time that,by this means or some other, that Council be presented w th a studied result of these things before we even make a final decision on this. 3 Now, the reason I'd like to do that is because I 4 recognize.the wide interest that there is in many engineering -5 schools and in many ranks of government in this-kind of 6 effort, and I believe that if we take Galbra t 'Ooriously 7@ when he says, it,,took American Airlines $30 million, along 8 with IBM, to develop their reservations system for just givin@ 9 tickets at the airline counter, we have to realize that 10 pe e large investment.may be rha@s what looks to us like a v ry the kind of@in@estment you have to make in order to pass to 12@ e this kind of technology effectively. the point where you can us put our 13 have to decide problem now is that we 14 where weire ai.@ Do we know enough to abandon this or should 15 we concentrate the effort in perhaps 910 or something else, 16 and keep it,going even though it is expensive, because we can 17 reasonably anticipate a very large system benefit out of it 18 when it's done? 19 DR. MARGULIES: Well,, in fact, I think the@id6A 20 is not only an important and useful one, but I would like to 21 believe, particularly in light of the reorganization that was 22 described yesterday, that we can ekoand that.eff6tt and,bring 23 back some level of understanding to the Council of activities 24 which are not only in RMP but i other n P-5 structure that we work with- and I think we can move toward 56 that kind of@A goal. R&D has been in it; community@Health 2 Services; NIMH; they all have these investments; and I would 3 be delighted to puch this concept with Riso and with Dr. 4 Wilson so that.we can begin to get a sense of the state of 5 the art and progress and failure and so forth and know what 6 we're doing. 7 DR. BRENNAN: Exactly what we did with multiphasic 8 screening, and 1 think it helped us A great deal, and I@think 9 we have to do that now and spend a part of one of the next @10 s6ssionsi an hour or soi discussing such a report that we've had a chance to look into before we get to 12 DR. SCHREINER: Ilhat would you p do with ropose to., 13" this proposal? 14 DR. BRENNAN: Defer it. 15 DR. @SCHREXNER-, Defer action? DR. MARGOt!88: It won't work. 17 DR. DE BAKEY: That would mean that you're hot 18 going to give them the money, As I understand it,, it's an 19 emercrencv situation,, isn't it? 20 DR. KOMAROFF: Right. From January lst through 21 June 30th; they won't have any additional money. The questioi @22 is whether they can redirect money that," e in their 23 overall grant into this activity, 24 DR. DE BAKEY: I don't see any reason to defer it. 25 You have made amotion which seems to me a positive motion. 57 1 it's just a question of whether or not we want to approve 2 that motion. 3 DR. BRENNAN: Well, I feel it would be more 4 prudent for us to think this thing out. I think that the 5 proposition of turning this into a contract, perhaps a 910 6 contract, appeals to me more than shutting off something in 7 which we have invested $7 million. 8 DR. DE BAKEY: Well, his'motion doesn't reall ut. y 9 it off. it simply says "find the money within your own 10 budget. DR. KOMAROFF: There's no reason why we couldn't 12 make this explicit that this shouldn't be interpreted As a., bias toward a future request for money. 13 @14 PR* PAHL: Are you ready for the question? 15 DR. CANNON-.-. We did substantially cut that funding, 16 though, you seer so that they may hot -- it may hot be easy 17 for them to redirect funds. I mean, they are on a budget 18 which is substantially lower than they had contemplate -1 you 19 @remember, not even enough to continue the salaried ph -4ciAn s 20 that they had. 21 DR. BRENNAN: They could end up, given their 22 fixation on this program, cutting out things that we really 23 think are important in order to keep it operating. That's a 24 problem with this. Ile know the way that Regional Advisory 25 Group feels about this thing. It's 'Obviously been a kingpin of their program right from the outset. So I think what 2 youvre really sa ying is that they re going to cut otLer 31,p rams in order to do this. 4 DR. MC PHEDRAN: I wonder whether we really do 5 know how they feel about it, because I would have thought that 6 if they felt that strongly about it that the repeated 7 suggestion that they show us some evaluation would have been 8 followed. The suggestions are after every site visit. HOW 9 do they feel about it? The ression that we have gotten is 10 that this present request and the decision, as Dr. Komaroff 11 says, overspend for thellast si,x months,,,;really werii support 12 for the idea really of doing it really was gotten because of 13 some favorable publicity for this project. So I reall wonder y whether we're misinterpreting strong feelings of the Recrional 15 Advisory Group. I wonder if that isn't putting it a little 16 too strongly, 17 MRS. MARS: Is there any possibility of getting 18 funds from any other source to carry it on? 19, DR. KOMAROFF: Some of the activities have already 20 gotten funds from other sources, V.A. 21 MRS. MARS: I mean this projedt. 22 'DR. KOMAROFF: The region apparently pursued other 23 sources of funding within HSMHA before indicating to us that 24 they had to request an@additional $1500000. 25 DR. MARGULIES: Let me also remind you that one of 1 the implications of Dr. Komaroff's report -- two of them 2 one of them is that what they're asking for is money to carry 3 them through until the end of the fiscal year with no indi- 4 cation of,what happen8@thereaft6r, so one can assume that 5' there will be a continued request for RMPS support for this- 6 and not onl that, but this carries with it at least a verbal y 7 tent to expand that activity into other settings. So it 8 @would verv Possibly lead to a multi-oli nds of 9@ Activities within the Mi8soUri.Regional Medical Program.@ That 10 has not yet'been presented but there has been a clear state- ment th@y$@d like to move it into a multi-member practice settin4;- etc* 13 DR. PAHL: Donna,, do you have anything further to 14 add? 15 MISS HOUSEAL: I just want to concur.with@ Dr. 16 Marguliest comments. I discussed with the region their plans 17 for these activities for the next one to three years, and they 18 have two budget plans for next year; the larger one, which 19@ would include approximately a $1.4 million request for these 20 types of activities, would include field testing it in a 21; community hospital setting, and two group specialty settings,, 22:@, and then possibly, also, putting a@module;in a small unity 23 without a physician and linking it to Dr. gags' office. 24 DR. PAHL: Thank you. Is there further discussion 25 on the motion? if not, the motion is for disapproval of the 60 request by Missouri, All in favor of the motion, please say 2 ,Aye." ('kayes 4 DR. PAHL: Oppoadd? 5 BRENNAN: No. 6 DR. CANNON: Noe DR. PAHL: Two opposed. The motion is carried. MR. OGDEN: Would it not be rooriate immediately app 9 following this action for the adoption of the motion along the 10 lines that Dr. DeBakey has suggested; that there be an analysis 11 of this whole sort of thing now done? 12 DR. DE BAKEY: You make it and I would Second it'. 13 MR@* OGDEN: Iwill make such a motion. 14 DR. DE BAKEY: I second it. 15 DR.@PARL: Does the Chair understand the motion to @16 be an analysiIs by staff of the current state of activity of 17 our overall effort in this area? @18 NIR. OGDEN: Yes. 19, DR DE BAKEY: Yes. 20 DR. PAHL: All right. You've heard the motion. 21 analvsis designed 22 by staff. Let me be sure that youunderstand that i'm 23 interested,, and I hope the Council would be interested, in 24 having the Director determine how best to do this and call 25 upon whatever resources he may wish to do it. 61 MRS. WYCKOFF: And could we have a report at the 2 next meeting? 3 DR. PAHL: Yes. This would be an agenda item at 4 bur next Council meeting. 5 DR. KOMAROFF: Is it understood that the motion 6 includes a statement that this should hot be construed@ais the 7 final dismissal of this kind of activity in Missouri, but only 8 a denial of a specific reOuest for additional funds? 9 DR. PAHL: Yes. This is the understanding of'@'the 10 motion, 11 DR. BRENNAN: Would it be possible for'Cbuncil to 12 sit still for the suggestion that having done this with 13 respect to a regular grant application that they've made to 14 us, that we@transfer this function to a contract arrangement 15 r 910 and negotiat4i@with Missouri to@determine the fundi ng 16, required under such a contract for the supervised contin uance 17 e m une? of this general program oh an iht ri basis until i 16, DR. CANNON: Not until we hear the results of e 19 study. 20 DR. BRENNAN: wells wait. All I'm proposing in 21 thia is that we remove this from a loosely administered 22@ th 104P,.central office. This thing, after all, 23 has inter-regional significance if it ever works out, and it 24 seem to me that it's the kind of thing that you could contract 25 for under a910. 62 I Now, if we no longer follow the loose structure 2 that apparently hasn't worked out well in terms of getting us 3 reports and real status on what has been accomplished or even 4 a control of what's been accomplished, move over into a 5 contract mechanism and put a good,contract officer on it; 6 wouldn't we then kind of have the best of both worlds? We 7 wouldn't tape down,the team that's operating here. We 8 wouldn't lose the impetus of the program if subsequently we 9 judged that it is good; and at the same time, we would have 10 given the region a message-@hat there's going to have to be A 11 different approach to the administration and evaluation of 12 this effort. 13 I think that this@ would be a prudent compromise for us to-,make in view of the high levels of interest amongst 15, cy-making authority on c pme people with,@poli m6di Al develo nt @6 work in the government at the present time. I don't see any 17 reason not to try to accommodate ourselves to the division 18 ,of people who are certainly as bright as we are about-the 19. potentiality of these things and overrule them, in essen e, 20 here. 21 DR. DE BAKEY: It's hard for me to believe that 22 the interest7is that high at that level that they couldn't find $150,000@@for this, DR. BRENNAN: Well, I'm sure that Sanazaro.coul 25@ write him a contract just like that. 6 3 1 DR. DE BAKEY: That's exactly the point I'm making 2 and I'm sure they have already gone to that source. I would 3 say it would be,more prudent for us to await the assessment ol@ 4 this study before we make any decision of any kind one way or 5 the other. That's another reason why I think it's important 61 to make this study. After all, if there is that kind of @7' interest at the level you're talking about I'm sure that 8 within that area they could find money to survive, $150,000. 9 DR. MILLIKAN4. Well, I was just going to say in a sense this activity is the Missouri RMP, and I don't know how much of that we want to contract andhow much we want to keep in,the traditional pattern of support for an RMP. You see what I'm getting at? I think it would be wise to hear the 14 report of our study and then make a decision about whether we 15 want to support it at current levels or an increased level or 16 whatever. 17 DR. MARGULIES: I think that at the very least you have fered us some alternatives and some negotiating @19 instruments. are a variety of ways in which we could 20 pursue the contract issue with RMPS,funds, with other kinds 21 of funds,@ If the.level of interest is high enough and the 22 @'contract @ae@@ reasonabl e, then I agree it should not 23 be difficult to locate the funds to continue it, 24 MRS. WYCKOFF: Do you need a resolution for a contract if we decide that it's necessary? 64 1 DR. MARGULIES: No. 2 DR. BRENNAN: I'd ask whether you wanted to enter- -3 tain quch a motion. There is no formal motion on the floor. 4 MR. MILLIKEN: Don't we have a motion to study 5 this thing? 6 DA. PAHL: Yes. All in favor of the motion to 7 conduct a study and reloort the progress of the design of the 8 study to the Council at the next meetin please say "Aye." 9 9 ("Aye'$) 10 DR. PAHL.- Opposed? 11 (No Response) 12 DR. PAHL: The motion is carried. 13 may we adjourn and get our coffee and doughnuts, 14 and then following coffee, we will primarily be concerned 15 with the kidney proposals'and some items of business from 16 yesterday. 17 (Recess) DR@. PAHL: May we reconvene, please. 19 DR. MAItGULItS: we have some other iaguei§'which we 20 must address at the present time. I*d like to have just a 21 quick report back to you on one of the questions that was 22, raised before the coffee break. During the 167-70 period of@; 23 RMP, if you combined automated technology and other major 24 equipment purchases, the total comes to over $18.4 mill on. 25 This seems to@be large enough to justify some understanding 65 1 of what we got out of it. 2 Ohio underwent some discussion yesterday and we 31 agreed that since they have made the proposed changes that I 4 reported to you that we would ask two members of the Council 5 and, if we can, one member of the Review Committee who pre-,- 6 viously visited the region, to go out there. I have asked 7 Bruce Ever6ist and Clark Millikan, who have done something 6 similar for us,, to again perform that kind of'a duty in Ohio, 9 and they agreed. One of the people who was on the previous 10 site visit from the Review Committee was Geor46 Miller,, and 11 if we can get him to join the team we can get"some information 12 reported back to you. 13 Now, we,also have distributed for you to consider 14 with the understanding that it was well-written I altered' 15 it slightly and i t was less well-writteh as a consequence,a 16 resolution or not really so muoh'a resolution as@a proposec 17 tion of a i Council action regarding the crea cancer center n 18 the northwest part of the Unit6d States. I think maybe we 19 should read it aloud for the record,, which I'll be glad to dO4 20 ll%%e National Advitory Council on Regional Medical 21 Programs approves the anting of@$5 million for the con- gr 22 stkuction of a cancer center located in A major med ca 23 center in the area served by HEW Regioft X. 24 "The Center, while it is to be an independent, 25 nonprofit corporation should have, to ensure its perpetuity 66 and achieve its ultimate objectives organizational relation- 1 2 ships with a University Health Science Center and other 3 medical educational training and research facilities in 4 Public Health@Service Region X. 5 'In addition, liaison and coordination with the 6 Regional Medical Programs in its area and with the CHP (a) 7 agencies in t he,yarious states in' Region X should be fostered. 8 [#TO fulfill its unique potential for making available to those persons suffering from neoplastic diseases 10 subject to curative intervention through cooperative multi- 11 disciplinary treatment efforts in the area, a mechanism for 12 communication interaction and cooperation with existin 13 esearch and cancer related agencies in the region, cancer r 14 including the existing medical services and the hospitals and 15 voluntary societies, should be developed. 16 "The Center should be recognized as a regional 17 cooperative cancer center rather than the single most 18,, important institution in its field,, and every effort should 19 be made to ensure adequate regional representation at the 20 Center. 21 "The Center's planning and programs sh 1 have a 22 goal of making,feas@ible for all persons in need of cancer 23 treatment facilities available at a humanistic level. 24 "Other goals of this facility should be education 25 of all health professionals for, and the coordination,, 67 1 research and demonstration of, optimal patient care in the 2 field of cancer treatment. This Center would be the 3 appropriate recipient of a grant from the National Advisory :4 Council on Regional Medical Programs insofar as these 5 objectives are equally pursued. 6 'This Center would have the function of focusing 7 on the problems of cancer research and cancer treatment all 8 @the relevant resources of the advanced technological -community 9 'of.-the northwest region of the United States. 10 "The National Advisory Council recommends that this 11 Center include on its Board a representative group of 12 recognized leaders in the field of cancer in its region, and,, 13 further, that it convene to advise a Regional Cancer Council 14 tised of persons throughout Region X as well as a COMP 15 Scientific Committee to coordinate cancer research, education 16 and service and promote regional cooperative arrangements. 17 "And finally, the National Advisory Council 18 e efforts s.onsored by this Center be recommends that th p 19 afforded the advantage of periodic review and consultation by, 20 an Advisory Committee of nationall and internationally y 21 recognized authorities in this field." 22 DR. ME-RRILL: Should we include in this some 23 statement about provision for its continuing operational 24 funding; that it@3*-s our understanding that additional 25 arrangements for its continued operational funding? 68 1 DR. DE BAKEY: Harold, I presume you have already 2 discussed the basis of this and I'm not familiar with it and 3 I don't want to waste the time of everybody, but the only 4 question I would ask is, is this setting a precedent for the 5 Regional medical Program? I don't mind setting it. I'm@pot 6 questioning whether or not we should. Personally,-l think, 7 it's great. In fact, I'm glad to see us set a precedent. 8 DR. MARGULIES: Right. I see no reason not to. regard 9 it as precodent-settinge I think the one @ing-t-h.at has _not 10 clearly been in here and which Dr. Merrill appropriately 11 brought up is some statement regarding the necessity for an 12 effective source of funding and technical assistance to main- 13 tain the professional activities within this Center after it 14 has been constructed of the kind, of course, that the National 15 Cancer Institute could provide; and we could add that kind of 16 wording. 17 DR. DE BAKEY: That's good. 18 DR. EVERISTO. With that added, I move we accept 19 this. 20 DR. DE BAKEY: Second. 21 DR. MARGULIES: With that addition, the motion is 22 that this be accepted, It's been moved and seconded. Any 23 further discussion! All in favor, say "Aye." 24 ("Ayes") 25 DR. MARGULIES: Opposed? (No Response) 69 1 DR. MARGULIES: Thank you. 2 DR. PAHL: We have before us in terms of formal 3 applications the kidney proposals which were deferred from 4 yesterday's consideration and I would like to now return to 5 those,, the first one being that from Arizona; and'if I might 6 just ask Dr. Schreiner and Dr. Merrill to lead the discussion 7 and make appropriate motions on these kidney applications which 8 remain before us. 9 DR. EVE-RIST: Does that require action? 10 DR, PAIIL,, Yes. These are parts of the formal 11 requests of the regions which were not taken up yesterday in 12 the motions. We have three from yesterday which were not 13 Acted upon and then three supplemental kidney proposals. 14 DR. EVERIST: All right. 15 DR. PAHLI Dr. Schreiner, may I ask you to start 16 the discussion on the Arizona kidney proposal? 17 DR. SCHREINER: I thought in this instance the 18 general review of the Ad Hoc Panel on Renal Disease was 1 1 9 satisfactory. They have had a rapid buildup in good personnel 20 in this area, I suppose the most outstanding person being 21 David Ogden who has moved there from the University of 22 Colorado at Denver. 23 DR. MERRILL: And Stokowgky. 24 DR. SCHREI R: Yes. Stokowskyralso. 1-think they 25 have got the professional capability of mounting a program. 70 1 The site visitors recommended approval with some budget 2 modification land they particularly threw out the physician 3 education com nent which apparently would not be one of the @PO 4 strongest aspects of their proposal. 5 1 thought-ma be we ought to have some discussion 6 about the loan program because it seemed to me that this was 7 rather summarily dismissed by the Review Committee. What 8 they're proposing is kind of a, as far as I know, innovative 9 but I haven't been here too long -- in that they're proposing 10 a revolving loan setup Iwith a bank,@.prol*e'tlv supervised, in 11 order to initiate transplant, with the idea that the 12 -rehabilitated patient then will pay back out of his earnings, 13 if he is rehabilitated. This is kind of a positive feedback i 14 system that appeals to me, if workable,, and I wonder if other 15 people had some views, whether this would be a workable lr, experimentation. 17 DR. MERRILL: They do state in their discussion of 18 that that there is no guarantee that the total amount of the 19 that would put us in the position of loan would be repaid, and 20 paying,at least in part, directly for patient care; and I think 21 that's almost exactly what,would happen; and that may be the 22 reason for the unfavorable look at it. 23 I would agree with George on that. They do have 24 good peopIle. Their ideas are good. I think the Ad Hoc 25 Committee- has quite correctly thrown out not only the physician 71 1 education, but the so-called detection program, which is a ver@ 2 difficult one to implement and get any meaningful data from. But the rest of it I think certainly bears support and I would agree with the recommendation of the Ad Hoc Commit- el 6 DR. PAHL: Is there a motion? 7 DR. SCHREINER: I move to approve. 8 DR. PAHL: There is a motion to approve the 9 recommendations of the site visitors for the kidney proposa 10 in the Arizona application. is there further discussion by 11 Council? if not, all in favor of the motion, please say "Aye-', 12 ('Ayes 13 DR. PAILL.- Opposed? 14 (No Response) 15 DR. PAHL: The motion is carried. 16 Dr. Merrill, would you please lead the discussion 17 ion the('C61orado/Wyomingltriennial application kidney ,proposal? 18 DR. MERRILL: I must confess that when I looked at 19 that review yesterday I was unimpressed, but the original 20 application I think gives a much fuller description of what 21 they're trying to do. I had initially envisaged simpl from y 22 the summary that what they were going to do was to set out to 23 dialyze children as an end in itself, which I would heartily 24 disagree with and I think Dr. Schreiner would, too; but they're 25 not, if one reads the full proposal. 72 1 They are going to have cooperation with Colorado 2 Transplantation Center and that certainly has a tremendous 3 capability, and although they do not mention the people 4 involved by name, Igm sure that they are going to get involved 5 in that -- I'm sorry, they do here -- so that would complete 6 my approval of it. Now, some i4Q 7 on was raised "@out the fact as to 8 whether or not th6to@'sho-dld be separate facilities for children, 9 and I'm absolutely convinced there should. our own experience 10 leads us to believe that it's just impossible to take care of six- year-old kids in an adult ward. 11 12 They do have a good pediatrician in charge. They 13 ihave all the capabilities for dialysis and transplantation, and 14 I think the experience in California with pediatric transplan- 15 tation done under the supervision of pediatricians has been a 16 good one, as perhaps opposed to our owns and I would th3nk 17 this was well worthwhile. 18 DR. PAHL: Thank you. Dr. Schreiner? 19 DR. SCHRE-INTR: Tlhen we discussed this, as you 20 remember, we talked about the number of beds and I've since 21 had a chance to discuss this with staff, and apparently this 22 unit is continguous with an acute unit, and while funds are 23 not being sought for the acute unit, the actual arrangement of 24 nurses is going to be such that they will be or can be sprea 25 Over an adjacent unit, so that helps a little bit. 73 1 DR. PAHL: The Chair understands that there is a 2 motion for approval and it has been seconded for acceptance of 3 the site visit team recommendations,on Proiect.129 of tie 4 Colorado/Wyoming application. Is there,further.discussion by 5 tv I council? if not, all in favor of the motion, please say Aye. 6 (RAyes 7 DR. PAHL: opposed? 8 (No Response) 9 DR. PAHL: The motion is carried. 10 The last one which was deferred from yesterday, 11 Dr. Schreiner is the ?( Ohio Valle kidney proposal, and I wonder y 12 if you would lead the discussion on that. 13 DR. SCHREINER: Well, to be perfectly honest with 14 you, I'm not wild about mobile transport units for organs. I 15 They might work in a close geographical area, but it seems to 16 me that the goal of most of what we're doing -- for example, 17 the goal of the southeastern network, and the negotiations I 18 that have gone on with other multiregional programs -- suggest 19 that motion be in the other direction; and that is to enlarge 20 the dialysis applicant pool or candidate pool if we're going 21 to seriously try to apply typing; and if you're goingto do I 22 that, the idea of having a truck just doesn't work. You have 23 to be able to fly them around to the various areas and you I 24 have to get them there in a reasonable hurry and there's a lot 25 of portable containers that are suitablelf6r this activity. 74 1 It's true you can't,profuse them, but I guess some of the new 2 smaller incubates maybe John has had some experience with 3 they'ke a small fra,ction of the size of a Belsor and it may bel 4 that they would be suitable even for air transportation with 5 profusion going on. But at the present time, it seems to me 6 that you tie up a fairly large piece of expensive equipment 7 that's only working a small part of the time. 8 1 think of the difficulties that we've had locally 9 here funding the Heartmobile and how you can drive by that 10 hospital many times and see it parked there in the driveway 11 doing nothing. It does some things, but it's a lot of 12 expensive equipment to have for the short time that it's being 13 used, I'm not too warm about that. 14 DR. PAHL: Are you making a specific motion? 15 DR. SCIIREINER: I'd like to hear John first. 16 DR. MERRILL: I think in general I would agree with 17 you. I think the California experience has shown pretty clearly 18 that with@simple@profusion and cooling alone you can get eight 19 hours survivals and good function and the Belsor apparatus 20 will take you UP to 48 hours or even longer sometimes; and it 21 seems to me that their program should be pretty well established 22 before they can document the need for preservation beyond six 23 or eight hour -@period. 24 if-they can do that they're reallv setting into 25 more than a regional; theylre getting into almost a -- if you 75 need to hold something for 48 hours, you can fly it to 2 Australia if need be. So I agree, that I would rather see 3 documentation of the necessity for this and have them show us 4 the fact that they cannot do it with si ly eight hour preser-I MP 5 vation. 6 For instance, we have had kidneys from'Rochest6r ane 7 as far as Minneapolis which have not been put on the Bel@oor 8 type of apparatus. 9 DR. SCHREINER: This year, here in Washingtonp 10 had transplants from Atlanta,, Charlottesville, Chapel Hil 11 Richmond and Baltimore since last January, and we flew most Of 12 them in on commercial airlines. The one from Atlanta came in 13 on a commercial airline in a picnic basket. 14 E BAKEY: I would certainly agree with what DR. D 15 has been said, We have done the same thing and, in fact, have! been working experimentally with various m6thods of preservation 17 and have even developed one in our own shop where we can 18 preserve them and get along and function. I say, we have alsoi 19 lhad the same experience and we've been working with oreservati n ;20 chambers of various kinds, some of which have been developed in our own sh and while they certainly can be effective up OP 22 to 48 hours easily -- in fact, in one example it was longer 23 we have yet to demonstrate the need for them. it's a nice 24 sort of experimental activity and it's good to be able to 25 write a paper about it and talk about it, but -- and we've 76 1 spent quite a little bit of money on it, but we haven't 2 demonstrated the real need for it. 3 DR. MERRILL: It's a little bit like the Role vault 4 record. Evervbody tries to get an inch or an hour beyond the 5 lnext fellow. It really doesn't have all that meaning when you 6 get up to 48 hours. 7 DR. PAHL: Is there further discussion? 8 DR. MERRILL:, There is one other kidney project in 9 here and that is the dialysis technologist and I would 10 gather that that was approved. I would think that the man on the scene would be the important man to know about that. Do 12 they need a dialysis technologist? And that's already been 13 approved by someone on the scene and I would think it's all 14 right. 15 DR. PAHL: May the Chair have a motion for this 16 proposal. 17 DR. SCHREINER: I move for rejection. 18 DR. PAHL: Is there a second? 19 Second. 20 MRS. KYTTLE: That then has the effect of amending 21 the dollar amount previously recommended three years downward. 22 DR. SCHREINER: That would go down by the 69? 23 DR. PAHL: The dollar amount recommended yesterday. 24 MRS. KYTTLE: Providing that this was approved today. 25 DR. PAHL: All right. There is no misunderstanding 77 that@the final recommended level by Council for this appli- 2 Cation is such as to exclude the kidn ro a! if this 3 motion carries. Is there further discussion on the motion., 4 DR. MERRILL: The kidney preservation transports tioiL -5 system, because there is another one which is dialvsis 6 technologist? 7 DR. PAHL: Yes, sir, the one under present dis- 8 cussion. 9 is there further discussion oh this motion? If 10 not, all in favor of the motion, please say "Aye." 11 ('Ayes 12 DR. PAHL: Opposed? 40 13 (No Response) 14 DR. PAHL: The motion is carr e 15 Dr. McPhedran has asked that we discuss the Iowa 16 ap plication with respect to the kidney proposal. I was under 17 the impression that we had taken action on this yesterday, but' 18 if it is the CoLincills wish we may reopen this for consideration 19 lDr. MdPhedran, would you care to make a comment? 20 DR. MC PHEDRAN: No, I'm sorry, I think I should 21 have excepted it from my original recomendation because I 22 think that it, as set up in the previots discussions,@looked 23 as if it required special discussion. 24 DR* PAHL: I see. I'm sorry about theI misunder- 25 standing. I think the record should show, then, that the 78 action taken yesterday by the Council does hot include the sum 2 requested for the ki@ev asi3ect of that proposal Dr. Sc@rdiner 3'-or Dr. Merrill, would you be prepared to lead the discussion 4 on this aspect then? 5 @DR SCHREI NER:- I looked at this one. The only 6 thing that I would raise a question about in terms of the 7 review is whether or not and I'm not sure mechanically 8 whether they received a previous grant for subregional centers. 9 If they have, and they're in the business of setting up sub- 10 regional centers, then it seems to me that the staff forces 11 who are subregional center management might be a worthwhile 12 investment. 13 I think the short-term teaching programs don't 14 really excite me and apparently didn't excite the Review 15 Committee and didn't excite the site visitors. So I think I 16 would agree with their disapproval but I would ask whether we 17 are funding subregional dialysis center establishment in the 18 state; and if so, then we might revive that aspect, although 19 it was relatively small. 20 DR. PAHL: Can staff provide us some information 21 on the point raised by Dr. Schreiner? 22 MR. ANDERSON: I'm not sure I can comment on the 23 whole thing. I'm not sure I can answer his entire question. 24 I'll only speak to the issues which I'm familiar with. 25 The renal panel reviewed this application and this 79 I was the second application that had been turned down by the 2 Iowa IUIP. The Iowa RMP requested a site visit because it did 3 not feel that we had sufficient information or felt like we 4 needed additional information to make a determination. 5 Dr. Ed Lewis did make a site isit out there and I' v think Council members have his recommendation. This is a request for one year and Dr. Lewis recommended that it be 8 supported -- or that the nurses training portion of this 9 proposal be supported only. 10 DR. PAHL: Thank you. 11 DR. MERRILL: Well,, Iwould certainly agree with 12 @at, I think, as has been pointed out, their training program 13 perhaps is not the best written in the world, but I think it's 14 a very important concept and I wonder if a year of experience 15 would not allow them to come back in with a much better 16 proposal. I note that although the Ad Hoc Panel on Renal 17 Pisease disapproved it in toto, that the Review Committee 18 suggested that the nurse training portion of the proposal be 19 funded in part. 20 MR. ANBERSON: The panel said that they would go 21 along with the recommendation of the site visitors and the site 22,,isit was made after the panel had met, and the committee had 23-.he site visitors' report. 24 DR. SCHREINER: So that you're proposing $19,000 of 25 80 1 DR. MERRILL: Yes. 2 DR. I would agree with that. 3 motion has been made and seconded DR. PAHL: The 4 to approve the $19,575 amount relative to Project 23. Is 5 there further discussion on this motion? If hot All in favor 6 say "Aye." 7 "Ayes") 8 DR4 PAHL: Opposed? 9 (No Response) 10 DR. PAHL: The motion is carried. 11 DR. MARGULIES: I just wanted to report to you the 12 fact that when I talked to Jim Musser yesterday he pushed very 13 vigorously the idea of tyihg in more effectively and more 14 formally the facilities in the Veterans Administration 15 hospitals and we have agreed to get together and to begin to 16 work toward those linkages, which have been casual rather than 17 well-planned; and I think the circumstances are good for that 18 purpose. He has freedom to share his facilities now very 19 fully and we'll be coming back to you with a report of progress 20 on that. 21 DR. PAHL: We have three supplemental kidney 22 applications. The first one is from'Californial with Dr. 23 Merrill as principal reviewer. Mrs. Wyckoff, please, if you 24 will leave. 25 MRS. WYCKOFF: Yes. 1 DR. MERRILL: the California proposal is a 4i' ant of a@@-oroposal. I was reminded in reading it of the story o 3 the little boy who was drawing a picture with @is.crayons and 4 his older brother looked over his shoulder and said, "What are 5 you doing,, Johnny?' And he said, "I'm drawing a picture of 6 God." And his brother said, "Why, that's ridiculous. Nobody 7 knows what God looks like." And Johnny didn't even look up; 8 he said, "They will when I'm through." 9 (Laughter) 10 DR. MERRILL: And this is the kind of thing the 11 California proposal is. Now let me say, in all seriousness,, 12 that California has a tremendous competence. I know most of 13 the people. A number of them have trained with me and they've'! 14 aviation and they're doing extremely well got a tremendous org 15 Perhaps one of the drawbacks of their proposal is that they 16 are already established and doing so well. 17 They have, as you know, some nine areas; and of 18 lthe0e nine areas, six of them are already actively engaged in 19 the transplant business and they now propose to link all these .@O together, and they did this as the result of an original 21 application which was originally disapproved because of the 22 absence of an overall California renal program; but they were 23 given $122,000 in seed money with which to start this. They 24 come in now with a large proposal. 25 In essence, what they propose to do is the kind of 82 thing that they have already been doing, but to link it with 2 each other wi th a,computer bank, good tissue-typihg facilities 3 information on what happens to people on dialysis, what happen-c 4 to people on transplantation; and in addition, they propose 5 one of the most ambitious projects, and that is to have 6 California and California alone organize and set up a supply 7 of antilymphocyte globulin. I presume they will share this, 8 when perfected, with the rest of the world. 9 The proposal itself is rather vague and it has a 10 n@er of inconsistencies in it. I won't read all of them to 11, you, but I would like just to note a couple of them. They do 12 not tell us about where funds for donor kidney removal are 13 ;roing to be obtained,, although they do mention that it should 14 be utilized. They don't,tell &bout @hich'individuals'are.- 15 gpecifically going to be involved. They do include in their 16 :)udget in a very large way professional Dersonnel, including 17 Transplant surgeons and trainees in each instance, something 18 :hat we wondered about. 19 They state they're going to have a large conference @l 20 Iosting $4,000 f r I o planning the development in antilyphocyte 21 4rlobulin and this is, going to be supported by the Upjohn 22 Company who'to datoi'@has not been able to provide us with 23 antilymphocyte globulin because they're having trouble. They 24 are going to invite as a consultant Dr. Star@ , who said 25 only two weeks ago at the American College of Surgeons that in 83 1 sPite of the fact he was the first to use antilymphocyte 2 globulin, he had really no evidence that it had made an awful 3 lot of difference in his program. 4 So ey've got quite an ambitious plan wh ch rea ly 5 extends a program which is ongoing and ongoing quite effectively, 6 and they themselves point out that one of the reasons it is 7 is because they have done extremely well with third party 8 funding with Medical. 9 They propose to, in the State of California or t 10 California Region, have a number of these Belsor apparatuses 1 running around between hospital and hospital, and I'm quite 12 Iconvinced, since the data itself came from Los Angeles County that that i., 13 some time ago -- that is, the data I quoted you 14 not necessary. 15 1 think the upshot of it all is the recommendation 16 by both the Review Committee and the Site Visit Committee thatl 17 lthev be funded, but drastically reduced; and the figure that 18 lis quoted here in the blue sheet is $2l4i5OO out of a requested 19 $625t287 --r_a fornia in the present state o t art 20 can get along perfectly well on that. 21 DR. PAHL: Thank you, Dr. Merrill. Dr. Schreiner? 22 DR. SCHREINER: 1 think that what we're going to 23 have to do shortly, that we haven't mentioned in previous 24 Council meetings, is perhaps take into consideration the level 25 of state aid. This has been a rapidly changing situation 84 1 Nine states, if I recall the figures correctly, about three 2 years ago had any form of direct dollar aid for renal patients; 3 and it's grown in this period of time to 25,, the latest figurel 4 that I have. 5 1 think that in states where you have a well- 6 developed program of direct aid by the legislature and where 7 you have a very liberal Medicaid program, that a lot of the 8 kinds of things we're trying to provide to other people can 9 really be provided by that mechanism. in a way, I supoose it's 10 penalizing people for being progressive,, but on the other hand, if we have the concept of startup funds, then we ought to be 12 concentrating our -shots on the have-nots rather than the haves 13 in this particular area. 14 so I think this is an area that's done a lot of 15 fine work and they have so many sources now of financial 16 support that they can probably run this program on a reduced 17 amount. I would agree with this. is DR. PAHL: All right. It has been moved and 19 seconded that the Committee recommendations be accepted,,@@which,. 20 means that this sum of money is included within the existing 21 e further discussion on the motion? budget. Ts ther 22 DR. OCHSNER: May I just make a statement, Herb? 23 I would feel that we, recardinq what you said about funding 24 a transplantation surgeon, that we should not do this in a 25 state such as California where they have a plethora of 85 1 vascular surgeons. They can get plenty of people to help. 2 I felt the same way about Vanderbilt.@ They wanted us to 3 underwrite a transplantation surgeon. Now, they've got a 4 fine department of vascular surgery at Vanderbilt,, but if they 5 can get money from us to get another faculty member they watt 6 to do it. 7 DR. MERRILL: I think they have on their budget 8 something like six transplantation surgeons; that is, their 9 staff member and some six trainees. The Review Committee 10 pointed out that there was a qu6stion about the justification 11 of requestitg a por tibn of the salary of every transplantation 12 surgeon in the State of California. 13 By the way, California, which I found out from 14 this, is the first state to have a concrete society of trans- 15 plant surgeons, which is another indication of how medicine 16 is be ihg fragmented. com 17 DR. PAHL: Is there further discussion? 18 MRS. MARS: I*d just like to ask how much actual 19 duplication is there in the programming here that %.ie're 20 paying for as to what's being done already in the state from 21 6,ther sources ? 22 DR. MERRILL: There are two places in the area 23 which are not doing transplantation. One is the Watt$ area 24 which we discussed at the last meeting, and I think this is 25 certainly justifiable to set this up; and the other is Loma 86 Linda. Whether or not when they get through all of this 2 transplantation will be more than they need to take care of 3 the patients in this area requiring transplantation is 4 anybody's guess but right now, of course, they're getting a 5 good inahv patients from out-of-state. I don't think those 6 figures are available. It might be something to look into. 7 DR. PAHL: Thank you. Is there further discussion? 8 if noIt. all in favor of the motion, please say )tAye.11 9 ("Ayes") 10 DR. PAHL: opposed? (No Response) 11 PAHL: The motion e 12 DR. is carri d 13 May we now turn to the@Georgia application with 14 Dr. Schreiner and Dr. Merrill as discussants. The record 15 will show Dr. McPhedra n is out of the room, 16 DR. SCHREINER: In this instance, there are three 17 basic activities that are proposed for support4 one is the 18 existing transplant activity. The second is the subregionali- 19 zation and various aspects related to dialysis; And a third is 20 a development of a computerized clinical diagnosis and 21 management of acid base balance. 22 As you may or may not know, such a program is available and it's very cheap to rent. All you have to do is 23 24 pay for the teleph6ft6 line and the terminal, and this was done 25 up in'-Boston several years ago, and it's my understanding it's 87 1 available any place that you can get a telephone line. So I 2 think this would be a complete waste and duplication of effort 3 and I would be against it. 4 1 don't have in the papers that I was given a 5 complete breakdown of the transplantation program. There was 6 $211,000 requested and the Ad Hoc Panel recommended $46,000. 7- if that includes any funds for surgeons, I would second Dr. it appears to be a 8@ ochsner's remark and,delete them. If not 9 reasonable pruning of the request. 10 The area facilities probably are the most construc- 11 tiVe portion of this. There are good people in Georgia, 12 although they lost the sparkplug of the Brady dialysis effort s moved to Virginia. They are replacing him a 13 that wa nd I 1'4 don't think that the activity will be quite as high gear overi 15 the near term but they're developing replacement personnel 16 which will s them up a little bit I think. So I think low 17 providing funds up to $35,000 for the area facilities is a 18 reasonable request, and they recommended deletion of the 9 nephrology component at the centers as being part of the existing resources and this is also a difficult thing. I 21 would go along with my previous remark; that is, if you really 22 expect a center to provide backup, then they are going to have 23 to increase their staff by A little bit. So I would be in 24 favor of putting back at least perhaps a half a salary for each 25 center that is actually open. Now, if they don't open a 88 1 regional center, then I don't think they need that; but if 2 they actually did open one, I think a half a salary for a 13, faculty person is not unreasonable. The Ad Hoc Panel 4 recommended completely deleting all the in-center personnel 5 and I think I'd put back two half-salaries but make them 6 contingent upon actually opening up an area c6nter., 7 DR. PAHL: Thank you. Dr. Merrill? 8 DR. MERRIL]6: I think I agree etsentially@w th 9 what Dr. Schreiner said. 10 DR. PAHL: The motion has been made to ac t the 11 panell@s recommendations with the additional statements 12 Dr. Schreiner added r half-s-a inge con 44pcr the larv dont nt 13 upon the opening and functioning of the area centers. Is 14 there further discussion on the motion? 15 DR.SCHRFINER: And if the $46,000 does include a 16 surgeons salaryi I would delete that. 17 DR. PAHL: Yes. I'm sorry. I forgot that part. 18 Is there further discussion on this motion? If not, all those 19 in favor of the motion, please say "Aye," 20 ("Ayes") 21 DR. Opposed? 22 (No Response) 23 DR. PAHL: The motion is carried. 24 The last supplemental kidney proposal is that from 25 Rochester.@Dr. Schreiner, will you,please lead the discussio 89 1 on this. 2 DR. SCAREINER: I think I have here a little dis- 3 agreement with the Review Panel. We have some sup ,plemental 4 material that's dated September 1971, and itm familiar with 5 this, ard,' Of course, they have.a very well-developed medical 6 team in Rochester in terms of both large surgical commitment 7 b oth in neurology and vascular surgery. It's one of the beat 8 coordinated groups to that extent, and they have a good nephrology program with trainees and so forth. At the present time they have 41 patients with 11 terminal renal disease. The estimated area load within the '12 Area is about 45 to 50 patients a year. Their total capacity that now exists is for a total of 49 patients and this,is id6iiicted principally by two things: the lack of a physical 15 area at the Strong Memorial Hospital for care of transplanta- 16 tion patients; and then, the ability for them to plug in on 17 the Sony-West typing plant. 18, 1 think it's a well thought out plan. The hospital 19 is willing to contribute the space nd it's willing t pay for a 0 20 ten percent of the remodeling and whereas it was recommended 21 disapproval, 1 think that I would@like to conside t or 22@ approval. I think it needs some staff work on pruning the 23 budget a little bit:and I @'t make a specific recommendation 24 on that without further study, but I think it probably should 25 be funded at a reduced level,, 90 1 DR. PAHL: Thank you, Dr. Schreiner. 2 DR. MERRILL: I was amazed in reading this over, this proposal,,, to read that the Ad Hoc Panel on Re al D sease 4 recommended dis primarily on the grounds that the 5 project was unrealistic and not in line with current medical 6 thinking, because I wholly agree with Dr. Schreiner that this 7 is a fine proposal. It's quite realistic and it's completely 8 in line with current,medical thinking. 9 1 have only a couple-'6f reservations. One is; I 10 a ree, first,,@with Dr. Schreinek's comment about funds for 9 11 remodeling. I think that that should be'looked into very 12 carefully. Thev're simply@ oing to create a ward apparently 13 for transplant patients sd@that they won't be'scattered 14 around the hospital, and certainly the hospital should beak 15 its share of that'. 16@ I am not sure that the need four y 17 for a four-bed transplant unit, and I would reddmend dis- 18 approval of that item# if one can disapprove an item. L9 The@ohly other thing that bothers me a little bit 20 is the fact that this again, like California,, is an established progrcva. Tissue-typihg they say was undertaken in the fall ol 22 1969 and now the Ire asking fok supvort@6f this d they are y an to@.t in@wi h@ the Sony-West procjr but I would assume 23@@@ askin ie am Ci 24 '@from what thev ea here@that they ate,'ihdeed, the center for y inated program. They s e i instance, 25 this %,Yhole@ coord tat fo 91 that this laboratory, meaning the t ssue-typing laboratory, 2' serves the renal transplantation program and A newly 3 developed bone marrow transplantation program and the Sony- 4 West organ exchange program. Now, if that is true, how have 5 they supported this before this; and why is it necessary how 6 to come in with support for it or perhaps we should ask the 7 question how much in the way of supplementary,support do you 8 need for extension of this? 9 Ci ainly tissue-typing is.one of the techniques '-ifhich is reim ursible, perhaps more reimbursable than chronic 11 @diaivsis on,a long-term basis, and I would think this would 12 @@be a'self-sustaining operation. it has been in our han s. 13 I Would recommend that the project be funded but 14 perhaps if these questions could be looked into with reduction 15 in cost in these specific areas, 16 DR. SCHREINER: I agree. DR. PAHL: It has been moved and seconded to, 18 approve Proi6ct 21 but with negotiation by aff on the basis 19 of Council discussion. is there further discussion on'. this 20@ motion? 21 MRS. MARS:@ think that all'this b ng-s 'up again 22 the question of duplication of work and use of funds. We. 23 seem to be ge incr'in@@further and further into these kidney It 24 ro ec 9* spendin4@ ey,, and we haven 06t that much,;ooney p 25 to spend to be le to throw it around unwisely'and duplicat 92 1 work that is being done. 2 It seems to me that mote or less what Dr. DeBakey -3 suggested for the machinery part could more or less be done, 4 a review by staff, to see that we do not duplicate kidney 5 programs that have already started, and some sort of a survey 6 could be made. 7 DR. MARGULIES: Perhaps it's because we haven't 8 adequately brought you up to date on this, but, in facts that 9 @kind of.a survey has been conducted and we do maintain a @io review on a geographic basisof all of these rojects before p un they come in;,because the Co cil has expressed this concern 12 regularly as you have, so when we identify something like 13 clearly identif any other the prograin@it Rochester we very y 14 resources which a-re available. if there is evidence of, 15 duplication or if@it appears that someone wants to put some- 16 thi ng right next to what already exists, we do bring that to 17, the attention of Council. Le Perhaps we could be more explicit, however, when 19 we bring in these proposals so that you understand'it. In tha 20 past few council m6etin