L L 1 MIA[. Transcript of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE IISMIIA REGIONAL I-IEDICAL PROGR-WI SERVICE COUNCIL t4mt G. Pockville, Maryl-tirid Tuesday, 17 October 1972 ACE-FEDERAL IIEPOII'I'ERS, INC. Official i?eporters 415 Second Street, N.E. Telephone: Washington, D. C. 20002 (Code 202) 547-6222 NATION-WIDE COVERAGE CR 7535 i AL: paW 11 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 2 3 HSMHA 5 6 REGIONAL MEDICAL PROGRAM SERVICE COUNCIL MTG. 7 8 9 10 i3 14 15 16 Room G-H Parklawn Building 17 'Rockville, Marylan 18 Tuesday, 17 October 1972 19 20 2 1 22 2"3 @@ 4 25 2 CR 7535 C 0 N T E N T S AL: paw 2 3 AGE14DA:. PAGE 4 Texas Application 3 5 Mississippi Application 7 6 Memphis Application 13 Missouri I' ion 16 7 8 SoUthe ast Application 41 9 Metropolitan New York City Application 73 10 I 12 14 15 1 6 17 18 19 20 2 1 22 23 24 25 3 SPARKS #1 I P R 0 C E E D I N G S mm er7535 2 DR. MARGULIES: Will the meeting please come to 3 order. 4 MR. OGDEN: The microphones are not on. 5 'DR. MARGULIES: I will project my voice to begin 6 the meeting. 7 We will continue with the review we initiated 8 yesterday, and we will try to move through the applications 9 at a steady pace, so that if there Are other subjects for 10 discussion remaining from yesterday, we can get to them. I will@'tukn to Dr. Pahl now to pick up the 12 applications, which I believe will begin now. 13 Id like to have us turn our DR. PAHL: I wou 14 attention first to the Texas application with Mrs. Morgan 15 as primary reviewer, and Dr. Schreiner as a backup reviewer, 16 with Dr. Meyer being absent from the room. 17 MRS. MORGAN: IThe site visit was made to xxxx 18 Washington, Texas on August 1 and 2. Drs. Miller and Pabla 19 were included on the site visit team, both of whom had been 20 on the site visit a year ago. 21 We addressed ourselves to the advice letter of 22 August 1971, that is, number 1, priorities must be established, 23 number 2, subregional staff members receive more assistance; 24 that allied health groups be -represented on the executive 25 committee and the RAG that minority group members be 4 1 represented in executive committee, the RAG and staff, and 2 attention to assessment of mutual needs and problems to be 3 made. 4 The RMP program of Texas has developed priorities 5 which were the basis for the proposed thre0@year program. 6 Objectives should be further developed in more measured 7 terms which should be corrected with the employment of a 8 qualified evaluator, a now vacant position in the program. 9 There was increased evidence of support and 10 assistance to@the subregions. The cooperation with local CHPB 11 gencies, planning groups, rather than forming local RMP a vxsory groups appears very prac 1 m 12 ad t'cal at this ti e And 13 include peripheral involvement. 14 Expansion of allied health groups has been 15 limited but includes the appointment of a pharmacist and so 16 forth to the RAG. 17 The Texas RMP has excellent strong leadership in 18 their coordinator, Dr. McCall. He has had opportunities to moie 19 on to other regions, but felt very dedicated to the Texas 20 program, and has the loyalty of the people being served. 21 The deputy coordinator, Mr. David Ferguson, 22 is also outstanding in his performance of duties. 23 They do not interfere with the freedom and the 24 flexibility of the RAG. 25 There is ample evidence that the TExas RMP has 5 mm3 I attracted funding from other sources for many of their 2 programs. Of the 19 new and continued projects, 16 3 anticipated other assistance from other sources for partial 4 funding. L 5 of the 15 terminating projects, 12 of these are 6 being funded from other sources or are self-funding and will 7 be continued. 8 They have developed a statewide coordinated compre.@ 9 hensive regional program which appears to be well developed, 10 well thought out$, and it has been my pleasure to see it. 11 Progress in minority involvement has been slow. 12 However, they have developed a positive action plan for 13 recruiting in 1973-74, which should correct this. This was the area the site visitors felt required a greater doncen" 14 15 tration of effort along with greater involvement of non-positidn 16 members in the RAG. 17 The RAG members who are physicians are in private 18 practice in the entire state, rather than the university, 19 especially Houston-based physicians. 20 The site visitors strongly wish to go on record 21 for a continuing rate of A for the Texas RMP. 22 The committee concurred with the site visitors for 23 approval of triennial status including a development 24 appointment. 25 I recommended we accept the funding recommended, 6 mm4 1. but that the program be reviewed in nine months for greater 2 minority involvement in staff and RAG. If this has been ished, the funding for years 06 and 07 will be 3 aCCOMP1. 4 considered. 5 DR. PAHL: THank you. 6 Dr. Schrein6r? 7 DR. SCHREINER: Yes, I concur. 8 This is one of the good places where the fellows 9 are speaking to each other. This is a significant part of 10 the program. 11 The significant part of the program is growing 12 and I think the recommendation for considering the request6d dollar amount for the second year is very appropriate, and I 13 (@j 14 would second it. 15 DR. PAHL: The motion has been made and seconded. 16 Is there further discussion by the council? 17 (No response.) 18 if hoti all in favor of the motion tated, 19 please say aye. 20 (Chorus of ayes.) 21 DR. PAHL: Opposed? 22 (No response.) 23 DR. PAHL: The motion is carried. 24 Dr. Merrill, we have given you A pause here now, 25 and perhaps we can now return to the Mississippi application. 7 MM5 You served as our primary reviewer with 2 Mr. Hiroto as backup reviewer. 3 Will someone get Dr. Meyer from the hallway? 4 DR. MERRILL: I participated in the site visit xxxx 5 to the Mississippi regional medical program in June, and 6 we found, as you know, that at the previous site visits 7 were some recommendations, that had been addressed to change in the Mississippi program. 8 9 The RAG and the program staff had been quite restructured, and the Mississippi program hot only dealt 10 11 with many of the criticisms and recommendations of the 1971 12 sitei, visit, but had moved forward in accomplishing other goal3. 13 All of us were impressed with Dr. Lamkey, who is or, and with a majority of the staff, some of 14 coordinat 15 whpx are quite new. 16 Some of the projects which they had already 17 accomplished included a health expor in which some 60 voluntary 18 agencies participated, and MRMP provided, some $8000 for ig seed money for this, along with a good many program staff 20 man hours, and they had attendance of some 60,000 people, 21 where there was considerable o rtunity for individuals. PPO 22 we felt that coordination between the university medical center and the MRMP appeared extremely good, with 23 24 many members staffing both groups. Here, II must confess that although it does not 25 8 nm6 appear in:the recommendations of the Review Committee or the 2 site visit, I was a little bit concerned about this. A good 3 many of the people on the staff of the university medical 4 center were being paid salaries, and from MRP money, 5 and were obviously going to have to turn to something else 6 once this was phased out. 7 But I think in general,.we felt that they were doing 8 as well as they could under the circumstances. They have a 9 good renal dialysis unit with renal satellite units which 10 have been set up, and a very active renal mani Dr. John Bower. They have increased the number of midwives in 12 the county health improvement program, and although their 13 previous neonatal death rate was the highest in the country, 14 this has dropped very dramatically, I think, as a result 15 of this program. 16 They have an excellent stroke care demonstration 17 center, with courses developed for physicians, who spend five 18 days in the ward with a neurologist. They have a preliminary 19 training program. 20 Their coronary care unit,which was founded At the 21 University of Mississippi medical center has trained 120 nurses 22 in coronary care and set up a number of other coronary care 23 units in other hospitals. 24 One important part of their program has been the 25 f dental hygienists, and this is particularly ,raining o 9 mm7 important since Mississippi has no dental school. 2 Dr. Lamton and his staff, I @.@hink, have gone 3 to considerable effort to help minority professionals in 4 obtaining hospital privileges in several instances, and although 5 this does not appear in detail in either the site visit report 6 or the report of the goview Committee, they have put in a con- 7 giderable amount of effort in this. 8 They have already encountered a considerable number 9 of problems, but I think the important thing is that 10 they have really attempted to do everything they can, and do it well. 12 The PRMP staff has also been involved with a 13 preceptorship program for black medical students, in an 14 attempt to bring black medical students back into the stateland 15 again real efforts have been made in this direction,, although 16 there are considerable problems in this area which do not 17 appear in the reports. 18 Nevertheless, we did consider these problems, 19 both with some of the black professionals involved and with 20 Dr. Laftkton and-his@staff. Certainly every possible effort is 21 being made. I think it is extremely important. 22 I think the emphasis snood be on the fact that the 23 coordinator has provided strong leadership, the RAG has been 9@4 restructured, they meet more frequently, they take a much 25 greater interest in planning, and in reviewing and 10 mme evaluating programs, and in geteral with a few exceptions 2 which we will et to in a minute, they have, I think, fulfille@ 9 3 almost all of the criticisms that were made at the previous 4 site visit. 5 one problem they have is that the assistant direc- 6 tor for planning and evaluation is only half time. one of the recommendations of the site visit 8 grou and the REview Committee would be a full-time man for p 9 this position. 10 He does have a chi6f planning assistant who 11 impressed us, although he is a resident graduate with a 12 master's degree in urban atd rural planning, and as yet has p 13 tot the experience, but I think he certainly has the potential 14 for it. 15 In general, without going itto more detail on it, 16 there were a number of additions to the staff in the 17 restructuring of the staff, which I think represented real 18 progress. 19 The recommendations of the site visitors woke for 20 funding at A level of $1,926,984 for the fourth operational 21 year, and you will note that the Review Committee decreased 22 this becauSe of some of the uncertainties about ongoing 23 programs. 24 one particular one was a program to evaluate 25 hospital safety in all the hospitals in Mississippi, and we MM9 1 felt perhaps this was perhaps too ambitious and not well 1 2 enough thought out, and there were several others that were 3 considered individually. 4 You will note also in the recommendations of the 5 Review Committee that there is a considerable difference betwo3n 6 years 4 and 5, and that is due to the fact that kidney was 7 separately awarded and does not appear in year 4, where it is 8 taken into account for year 5. 9 And I certainly would recommend that we go along ith the approval of the triennial application at the lo w 11 fudning levels recommended by the committee. 12 DR. PAHL: THank you, Dr. Merrill. Mr. Hiroto? 13 MR. HIROTO: I would second the motion. 14 15 DR. PAHL: The motion has been made and 16 seconded. 17 is there discussion? 18 DR. XOMAROFF: I had gone there the year before, ani 19 at that time and subsequently, I know there had been concern 20 among a group of the staff that had been called dissidents, 21 all of whom have now left the program. 22 Was there any -- did this friction between a few people on the core staff and the majority of the core staff 23 24 and advisory group surface? 25 DR. MERRILL: No. I think we looked at this 12 1 very carefully, having been aware of it, and talked to all of mmio 2 the individuals involved, both in meetings and separately at 3 a later date, and it was certainly my impression, and I think 4 that of the other site visitors that they had a well 5 coordinated and satisfactory operation. There wasn't any 6 dissent or any difficulty any more. 7 DR. KOMAROFF: The other question is, whether 8 the programs for inhalation therapy and dental hygienists, 9 if supporting them runs counter to council policy about 10 established allied health professions support. DR. PAHL: Judy, do you want to respond to that? 12 MS. SIL$gkE: I would ask Mr. Torbert and 13 Mr4 Van Winkle to comment on that. 14 MR, TORBERT: Not to our knowledge. DR. MARGULIES: Thequestion is, are they leading to 16 new programs that are leading to credentials, or is this 17 upgrading of skills they are involved in? 18 MR. TORBERT: Upgrading. 19 DR. MARGULIES: Apparently it is an upgrading, so 20 there is no conflict. 21 DR. PAHL: If there is no further discussion, those 22 in favor of the motion, say aye. 23 (Chorus of ayes.) 24 DR. PAHL: Opposed? 25, (No response.) end I DR. PAHL: The motion is carried. 13 CR 7535 DR. PAHL: We would like to turn to the Memphis #2 dhl 2 application with Dr. Meyer as primary reviewer and Mrs. 3 xxxx Wyckoff as backup reviewer. The record will show that Dr. Cannon is absent. 5 DR. MEYER: As I am a neophyte, and I ha to 6 glean this without the benefit of a site visit, I would 7 like to call the staff and on Mrs. Wyckoff for assistance. 8 There is a reapplication in the second year of a triennium. Apparently, this is because the developmental 10 component authority had been previously withheld, This was due to a complicated regional advisory group structure. 12 i It had been composed of the mid 8outh Medical Center Council, -L3 which, however, did not represent all 17 counties, though it 14 wa s excellent. It represented basically only 14. This di not include all 11 counties. It only included 14t and this 17 included adjoining counties in Kentucky, Mississippi, and 18 19 Arkansas. 20 A group was formed of 36 members, and this 21 corrected the disqualifying factor by virtue of the 22 greater representation. This was also assisted and avoided a lot of complications administratively by 23 the multi state involvement. The current funding was 24 $1,627,000, and the new RAG requested $2,367,127. The 25 staff has recommended $2,252,000. This was to support the I I 14 dh2 current program. 2 The developmental component, $162,700, and to su- 3 pport selected new activities, including ambulatory health care centers in the neighborhood. This was for a 5 $236,300 amount. 6 The remaining was for selected activities under 7 contract, requests of $225,000. 8 The recommendation the reduction, rather, was 9 recommended because the review staff felt that this newly 1.0 formed RAG had not As yet been able to develop sufficient data in their plans for more members of the new council. 1-2 Apparently, there had been considerable discussions regarding the expanded community health service activities 14 and emergency medical service. 15 8oth of these were reduced. It is my imptesion 16 17 from reading over what was submitted to me that this is 18 an excellent program with a very competent group of hard working people in it, and it certainly should receive 19 20 support. I therefore make a motion that the committee 21 recommendation that the developmental component and the 22 $2 million be approved. 23 MRS. WYCKOFF: I will second the motion. 24 I only want to.make one comment. I hope so 25 much that every@effort will be made to get Dr. Culbertson 15 dh3 to employ an assistant for himself, because I feel he is 2 a very overworked man and it is hard to administer the 3 medical program of Memphis. It has so many agencies. 4 They really have done a marvelous job of helping that area 5 apply for Federal funds, and there ate cooperative relation- 6 ships, but Dr. Culbertson is overworked terribly, and he 7 needs an assistant, and I hope very much they will do something like California, and get an assistant who will 9 ge a representative of the very large black population if 10 at all possible. 11 DR. PAHL: Thank you, Mrs. Wyckoff. 12 A motion has been made and seconded to accept 13 the committee's recommendations. 14 Is there discussion by the council? 15 DR. MC PHEDRAN: Will they have enough money with 16 this funding recommendation, Mrs. Wyckoff, to do what you 17 suggest? 18 MRS. WYCKOFF: To employ the assistant? 19 DR. MC PHEDRAN: I mean to attract somebody to 20 the job. 21 MRS. WYCKOFF: I think the budget contains 22 enough to employ the new assistant. They do not want 23 them to increase staff otherwise, because they have heavily 24 overloaded, but this is a very important position. 25 DR. PAHL: Is there any discussion on the part I - 16 dh4 of staff relative to this point? 2 MS. KYTTEL: The staff's recommendation of 2.2 3 took into consideration the need to employ a deputy. This program's funding has been at a level that really has not 5 permitted too much movement in that respect, and also, 6 hopefully, funds for them to move into the emergency medical 7@ services systems area. 8 $2 million will make them make hard choices. $2.2, staff felt, would permit them to move into two areas. '10 They may have to make a choice of one. DR. PAHL: Thank you. Is there any further 1-2 discussion by council? If not, all in favor of the motioni please 14 say aye. 15 (Chorus of ayes.) 16 DR. PAHL: Opposed? 17 (No response.) 18 DR. PAHL: The motion is carried. 19 Will someone please get Dr. Cannon in the room,.> 20 Dr. McPhedran, t believe, we might now have 21 your report to the council on the Missouri site visit, if 22 you will, please. 23 xxxx DR. MC PHEDRAN: This was a site visit on 18 24 September. The purpose of the visit was not to review any 25 new applications, but to go over the progress of the Missouri 17 dh5 th' fq regional program. The progress, we hoped, is occurre, 2 since the last site visit and the last recommendations. 3 Ms. Silsbee and Dr. Farrell came along with members of the review committee and we were privileged 5 to have Dr. reeno serve as a consultant on this 6 site visit, which was for one day A kind of continuous 7 exchange of inquiries and advice, sort of,like a dialogue 8 feedback session with all of the pain and anguish that that entails. This is now in the second year of the Missouri gion ogram, in the second year of a triennial al kr 12 award, and the triennial award, when it was made, was made 13 without developmental component, because the Program in 14 staff# organization and in organization of the regional 15 advisory group, did not seem strong enough to warrant 16 developmental components, and that still seems to be 17 the case. 18 In addition to that, we have differed with the 19 Missouri regional program that we, the site visitors, and 20 RMPS, about the value of some expensive computer projects. 21 One is best known as the BASS project, a computer project 22 in a physics office in.Missouri. It seemed that the 23 use@ of the equipment'&nd the results of it@.really didn't 24 justify-the enormous amount of money expended on it, and 25 in 'addition to@that, technical reviews for example, 18 dh6 the kind of equipment being used as time went on made us 2 feel that technologically, the project really wasn't very 3 sound. That is in addition to the fact that it wasn't 5 even living up to its potential. 6 Now, a lot of favorable publicity had come to 17 the program from these projects, but the RMPS site visitors, review committee, and council were not much moved by this, 9 and we had recommended repeatedly and earnestly that 10 those projects be terminated. 11 This had been very clear before the triennial 12 award was madej but even after the triennial award, the 13 program came back with a request for supplemental funds 14 last fall to continue to support these activities. 15 This so exasperated the review committee that 16 17 they wanted to withdraw triennial status, but we didn't go along with that, but did feel that additional site 18 visits would be useful in helping to got the message to 19 the region. 20 Meanwhile, the region has gone to health services 21 and mental health administration through a contract 22 mechanism. I was going to say so much for that, except for 23 the fact that the regional advisory group leadership 24 apparently misunderstood, at least this was apparent in 25 our site visit, where 'this additional 'support came from. 19 dh7 They thought it had come through the RMPS granting 2 mechanism, that we had relented after all these advises, 3 but we gave them to understand that it didn't come through the RMPS granting mechanism, this additional support. 5 These computer based projects and all of the 6 diversities of opinion that arose,'it seemed to have a 7 horrible fascination for site visitors from RMPS, but it 8 is really only a particular manifestation of what has seemed to be a basic problem with the program. We felt at this time that the program staff was,beginning to seek out problems in the region beginning -2 to look for solutions to th roblems whereas previously ese p they have taken the position that they should wait for 14 projects and new activities to be submitted to them. 15 The argument has always been made that this has 16 17 been done so'as not to hinder the local flavor of any project, but it has always resulted in the lack of any 18 cohereent direction to the program activity as a whole. 19 Now, the very large program staff is beginning 20 to work on setting priorities, goals, and objectives, and 21 they are looking around for ways to implement them. There 22 are several 16rojects that could be cited as examples of 23 this. The one that is most often cited is the so-called 24 Green Hills project, which is a series of cooperative 25 arrangements that has been fostered between a group of 20 dh8 of hospitals that were having a great deal of difficulty 2 in surviving by themselves. 3 This is the kind of thing that they are going to us e as a model, apparently, throughout the region, and it is a good model, although, again, Mr. Toomey, of 6 our site visiting team, who is director of a hospital 7 system in Greenville, South Carolina, Mr. Toomey was in 8 a position to make some very intelligent criticisms even About this fairly successful project. 1.0 Whether or not a staff of a program, a program staff, which has been built on the old policy of waiting 12 for things to come in from the region and then working 1 3 them up into some kind of a project, whether or not they 14 will be able to change direction and provide direction of the program more from the centeri is another question we weren't really sure about. 17 18 In connection with this, we were astonished that the director of the program is there only 54 percent of the 19 20 time with the program. The director has assumed another 21 responsibility in a consumer education program, part of the university extension activities. 22 We though that this was aft inappropriate thing. 23 We thought that he sh6u ith the regional 24 medical program, and waste 25 We don't know how this is going to be resolved 21 d,h9 although the director said if he had to choose between 2 the two activities, he would choose the Missouri regional 3 medical program. But that he would have taken this step and taken 5 on this Additional responsibility, I think, is a reflection 6 of the fact that he and the staff as a whole, I guess, 7 didn't really understand how concerned previous site visitors were about the lack of coherent direction of that program. 9 I think that is really the message I want to bring to you I 0 about that. Now, also, the regional advisory group is 12 1 not really representative of all of the'forcesithat@, should be. There is no VA representation on it. CHP 14 representation is also absent, but there is no particular 15 criticism, there being no necessarily critical size for i7 a regional advisory group, but it lacked some of the official representation that it should have, and also minor representation was notably lacking. On the other odds and ends abou he program 20 that we felt could be criticized are, first, their 21 review process, which is slow and cumbersome. Second, 22 their lack of an evaluation section. They need that, 23 but they know they need that, and they are working on 9-4 that, and also working on having some measurable sub- 25 goals and objectives that could be used by an evaluation 2 2 dhlO team. 2 So, in summary, we thought that we were able to 3 get across to them these continued criticisms. We do see some evidence of improvement in the program as a who e. 5 I know I haven't said much about that, but we did see in 6 the program staff efforts to develop measurable objectives 7 that they were looking toward a new dayt and also we found 8 that the subregional directors that they have in the state 9 were a competent group of people and were probably better 10 able to assess the heeds of the subregion than people 11 have given them credit for when we began the site visit. 12 So we learned something from them, too. There is no new money here that we have to talk about. We are 14 not talking about changing the grant or taking anything 15 away,, or adding anything on. We are simply giving A progress 16 report on recommendations that we made before, and in 17 short, siome progress has been made. We hope that it will 18 ,be better, and we do think that the dir6tor does need to 19 be full times among the other recommendations. 20 DR. PAHL: Thank you very much, Dr. McPhedran. 21 I believe the topic is open for council discussion' 22 MRS. MARS: Would the coordinator, if his salary 23 were raised, probably not consider Another job? Are they 24 payin too low a salary, and was he forced into taking 9 25 that position? 2,3 dh 11 DR. MC PHEDRAN: I think the salary was about 21 3 the same. It was a different division of time, and a 4 different source of money. I think he was asked to ta e 5 on this additional responsibility, or it was suggested 6 that he was the right man for the job, and indeed he may 7 be the best man for the job. 8 it is just that it seems that doing @both of 9 them would be clearly too much. 10 DR. SHREINER: What is the size of the contract? 11 DR. MC PHEDRAN: You mean for this continuing 12 education? 13 DR. SHREINER: No, the direct contract. 14 15 DR. MC PHEDRAN: I don't know. 16 MISS HOUSEAL: $15Q,000. 17 DR. MARGULIES: Donna, could you go to the 18 microphone Perhaps it would be a good idea to cover 19 the details of this contract for the council. 20 MISS HOUSEAL: We are presently extending the 21 contract to the end of December to allow time for the 22 National Center for Research and Development to develop 23 a new contract which will pick up support for this activity, 24 so I thIink RMP's days with this activity are soon coming to aft end. 25 The support, as I said before, was about $150,000 dhl2 for six months. DR. P4ARGULIES: Thank you. 3 DR. PAHL: Mr. Hiroto? 4 MR. HIROTO: Dr. McPhedran, if this were not 5 merely a progress report, would the visitors have made 6 specific recommendations? 7 DR. MC PHEDRAN: You mean would we have made 8 recommendations, for example, about awarding triennial status now? 10 MR. HIROTO: Yes. @,DR. MCPHEDRAN: I don't know. I guess maybe this year we maybe have been more easily persuaded of the review committee's position on triennial status, that it 14 wasn't appropriate. I guess s would have been. It really 15 end 2 didn't come up, and we didn't discuss it. 16 17 18 19 20 21 22 23 24 25 mea-1 25 CR 7535 3 MR. OGDEN: This raises a question possibly for 2 my own education -- if we have any authority to withdraw a triennial grant once it has been given? DR. MARGULIES: Yes. This was the recommendation 5 last time of the Review Committee, but Council felt 6 they did not want to uphold that recommendation. 7 DR. MC PHEDRAN: Mr* Hiroto, maybe I ought to 8 backtrack on that a little bit. I would really have to think 9 about that a lot before making that recommendation. 10 1 do think there are several things about the 11 program staff's activity which have been very helpful, and 12 I do think the subregional directors were pretty good, and 131 doing a creditable job. @14 I think the direction from the top -has not been good, and I wouldn't hedge on that at all, and I think that 16 maybe that is the principal difficulty, and maybe this 17 having to make a choice now will resolve that. 18 I don't know whether it will or not. 19 MR. OGDEN: What have you done; have you written 20 him a letter; has a letter gone to them? 21 DR. MC PHEDRAN: I believe a letter will go to 22 them after these deliberations now. 23 DR. KO@OFF: Did you speak with any of the 24 members of the Advisory Group or the grantee about the top 25 leadership, and did they seem to appreciate it? 26 mea-2 DR. MC PHEDRAN: No, we didn't do that this visit. 2 I think that that is probably something that should have 3 been done, looking back. 4 DR. MARGULIES: This site visit became altered 5 practically in midflight, because it was the recommendation 6 of the Review Committee and the Council initially that the 7 site visiting ought to explain in the clearest possible terms 8 the great concern which the Review Committee and Council hid 9 with the program. 10 In the interim, the program began to realize that 11 the Council had been very serious and very determined about 12 what was to be done out there,, so before the site visit 13 actually arrived, they had undertaken some striking changes, 14 which you have just heard about. 15 Then the site visit ended up being of a different 16 kind than we initially intended. 17 DR. PAHL: Judy, do you have anything to add? 18 MS. SILSBGE: There was a problem for several years 19 with the structure. When the structure was set up 20 originally, there were three different groups, and there was 21 a liaison group with health organization; there was the 22 project review group, and then there was a 12-mah group at 23 the top. 24 At one time they would say this whole three-group 25 body was the regional advisory group, and finally they 27 mea-3 decided that the 12-member group was the advisory group. 21 I think the site visitors made clear that once 3 having made this determination, they should stop worrying 4 about the other groups and make the 12-member group big 5 enough so that it met all the requirements for a regional 6 advisory group. 7 As it now stands, it doesn't. It doesn't have 8 some of the representation that is required. 9 The site visit team's discussions with the 10 members of the regional advisory group was probably the 11 most helpful part of the meeting, because they were able to 12 1 explain to the regional advisory group what Council was 13 expecting of them, and I don't think up to that point the i4, regional advisory group had really appreciated their role. DR. PAHL: Is there further discussion by Council 16 or staff? 17 DR. MARGULIES: I would like to raise another 18 issue related to this while we are at it. 19 Mrs. Curry wondered yesterday if we could at 20 least raise some of the problems involved with the 21 territories in Missouri, in the bi-state program, and 22 Illinois and not with the intention of being able to 23 resolve them here. 24 I would at least like to point to the fact that 25 they are going to require some special attention in all I 28 mea-4 likelihood. 2 The problems are different from those that we 3 addressed out in the northwest, and they consist of a real 4 conflict between the Illinois program and bi-state, which 5 is rather difficult to itemize, but which consists for 6 the most part of an understanding on the part of the bi-state 7 program located in St. Louis that it has responsibility 8 for those areas which are normally a part of the medical 9 service area of the large urban center that St. Louis is with 10 a rather remarkable collection of medical facilities of all 11 kinds. 12 This causes problems because it extends into IL3 Illinois in areas which are now a part of, or a projected ,L4 part of the Illinois medical education system, including 15 il I the Capital of the State in Springfield, where there are 16 RMP activities in bi-state, and extending further on 17 down where there is a projected medical school as part of 18 the University of Illinois system. 19 Thus far, there has been the feeling on the part 20 of the coordinator and bi-state that they can work this 21 arrangement quite easily, and a feeling on the part of the 22 coordinator in Illinois that it is not a tenable situation 23 and needs to be resolved. 24 Added to this is a growing pressure coming from 25 Al who is in the office of the Governor in Illinois, mea- 5 1 2 9 saying this is creating problems with CHP A and B agencies, 2 and needs to be resolved by central direction. 3 It seems to me they have in their correspondence in Illinois, that they have pointed to problems that 5 might exist rather than those that do exist. 6 Nevertheless, there is great uneasiness. 7 This also raises the question, and Alex, you may 8 have feeling about it,as to what role the Missouri RMP might 9 play in the resolution of this, because it might include -- 10 I am not suggesting it -- responsibility on the part of the 1 1 Missouri RMP for St. Louis if any rational change was to be 1.2 suggested. 13 I think you might easily respond to that 141 question, but I am willing to raise it for your consideration at this moment. 16 DR. MC PHEDRAN: Well, I don't really remember hearing much, or having much of a feeling that there was 18 any contest between the Missouri RMP and the bi-state RMP 19 over who was going to represent St. Louis in this activity. 20 I think that although I visited them just a couple 21 of weeks apart, I didn't get that feeling. Maybe I missed 22 something here, 23 DR. MARGULIES: No, I simply wanted your 24 confirmation. I don't believe that is an issue at all, but 25 I wanted to be sure we raised the question., mea-6 30 1 DR. MC PHEDRAN: I understood the differences 2 between bi-state and Illinois exactly the way you stated it, 3 and ifthe lines had to be drawn so that all of Southern 4 Illinois is included in the Illinois RMP, then the question 5 would be what would happen to St. Louis? 6 Is that it? 7 DR. MARGULIES: That would he a part of its, and 8 whether it makes sense to do it that way. 9 DR. MC PHEDRAN: It doesn't make sense according 10 to the original way that regional medical programs were 11 set up, because this is evidently a regional bi-state. They 12 made a very good case for that. How far north you go in Illinois in the region, .1.4 I don't know* 'i5 DR. MARGTJLIES: That has been our attitude, and 16 s' attitude was a reasonable one in the last letter 17 he wrote which came in two or three days ago. 18 He feels that those areas being served by bi-state 19 can work perfectly well in the CHP agencies in Illinois. 20 They don't have to be in the State of Illinois, if that is 21 the area of service, but it may require us to have some kind 22 of visit with the people out there to try to reach an 23 understanding so that they don't jostle one another as much 24 as they are attempting to do at the present time. 25 DR. MC PHEDRAN: I can understand the political 31 mea-7 I- importance of whether Springfield is in the bi-state or the 2 Illinois regional medical program district. I can understand 3 why the people in Illinois would be concerned about that, 4 but if it is looked at as a regional medical program, 5 bi-state has a good reason for being. 6 DR. MARGULIES: Dr. Schreiner? 7 DR. SCHREINER: I have toured that area as far 8 as the kidney facilities are concerned, and served as a 9 consultant to the new medical school when it started, and 10 there is no question that the kidney people were related 11 to St. Louis, but financially, they were getting money 12 from the State of Illinois; despite the fact that they had 13 a very high respect for the administration of the Illinois 14 RMP, they definitely expressed, everybody I talked to 15 definitely expressed a desire to stay with St. Louis. 16 DR. MARGULIES: It would be a little absurd to 17 ignore the fact that for generations St. Louis has been one 18 of the great medical centers of the country, and is going to 19 continue to attract people, because of its great skills, 20 whether it is in the kidney field or elsewhere. 21 It is a city which has two medical schools, many 22 great hospitals and has for years been one of the leading 23 centers of the nation. It would be unwise not to take 24 advantage of that fact. Sol I think it is really a matter 25 of working around the facts of life rather than trying to I 32 mea-8 change them. Mr. Milliken? 2 MR. MILLIKEN: I happened to be at a meeting with 3 Dr. s about 10 days ago, and this was brought up, and 4 I just happened to have in my briefcase a copy of the 5 subare contract which we used in the three-state 6 Cincinnati area, Indiana, Kentucky, and Ohio. 7 He felt it was the answer to the problem, and 8 he was going to use this in that area as an example of this 9 interrelationship which could go both ways, and tie it down 10 to specifics. This may help. 11 DR. MARGULIES: For some reason, I think Dr. 12 Cannon wants to be in this discussion. 13 DR. CANNON: I gather you detected my uneasiness. 14 I was going to wait until later and ask that we 15 discuss the presentation by Dr. Stone, but in your remarks, 16 Harold, I think it is appropriate that we discuss a matter 17 now that for a long time this Council has talked about, the 18 interests of the Administrator of HMSHA, and the regional 19 medical programs and its intent. 20 One of the original concepts was that the 21 regional medical programs was not going to interfere with 22 normal medical referral patterns, 23 Dr. Stone's presentation stated in the second 24 paragraph, emphasizing the attributes of the regional 25 medical programs number 1, "Its decision-mak powers ve 33 mea-9 I been decentralized to the final level in most cases. That 2 is, to the states or subregions of the states." 3 Now, we began on the premise that a region was 4 a .,logical geographic unit, and by logical geographic unit, 5 we meant it was the region defined itself by its wholesaling, 6 marketing, its purchasing, its utilization, its news media 7 coverage and so forth, as well as its medical referral 8 patterns. 9 Gradually, over a period of years that I have 10 beenon the Council, I have detected, and it was easily 11 detected, that there is a tendency to move this into the 12 states the state government process, and I believe that 13 such an attempt, no matter where it stems from, would be to 14 the detriment of the regional medical program. @15 I think that this Council, before this document 16 goes out, and there are other points I wish to discuss, . 17 should modify that first statement so it doesn't appear that only states and subregions of states are singled out as 19 being attributes of the decentralizing process. 20 I am very sensitive to this. We started in 21 Memphis because of the Mississippi River. it began many 22 years ago to be a region, .North Mississippi and Eastern 23 Arkansas and Southeastern Missouri,- Western Kentucky still 24 reads-@the "Commercial Appeal" and listens@to WMC 'And watches 25 WMC-TV. They come to Memphis to buy their clothes; they trade 34 mea-10 I on the cotton market, and it is a designed geographic unit 2 so far as the people and the way they associate themselves 3 with the center. 4 I can see that St. Louis is in much the same 5 situation. It would be wrong at any time that this Council 6 creates the feeling that there is a prerogative for the 7 state government or otherwise, health officials in the state, 8 to assume the responsibilities that this regional medical 9 program originally set out to do# and that is to enhance the 10 normal referral patterns, and not to destroy them. 11 I really think that this ought to be clarified. 12 DR. MARGULIES: Dr. BrennaA? 13 DR. 'BRENNAN: There is a little problem with this 14 position, unmodified, and that is that after our regions 15 were set up, the CHP program came into being, and one Of 16 the directives we have had, or obligations that we have 17 had, was to relate RMP to the CHP A and B agencies. 18 Now, they are all state agencies. So, we have 19 a little knot here, and I don't know exactly how to ge 7535 20 around it. End 3 21 22 23 24 25 jonl 3 5 DR. MARGULIES: Mr, M u like to 4 illikan, would yo 2 comment? 3 I want to remind you that Sewell is Director of 4 CHPA Agency in Ohio. 5 DR. MILLIKAN: In the legislation for CHP there 6 is a considerable number of paragraphs relating to the fact 7 that CHP is to establish, where necessary, interstate CHP 8 organizations. 9 We have one of the first and the best in Ohio 10 which is the area of Cincinnati. It is six counties in 11 Cincinnati. 12 DR. CANNON: I wish to correct that. Mem his p 13 as the first. w 14 DR. MILLIKAN: We will stand with that. 15 There are four in Indiana. 16 Through some adaptations that I mentioned before 17 this has worked exceedingly well, and the only problem has 18 been that it was soon dissolved in the regional office 1 9 where @e@had'to go to two regional offices to clear things 20 because Kentucky is in one regional office and Ohio and 2 1 India a'are@@,in another. 22 But this was quickly taken care of and the 23 federal government named one regional officer the ,)4 Chicago re ional office, to be primary. So the other region 9 25 just gets their information from them and I would offer the 36 jon2 -RMP-CHP re2,ati,onship in that area as one of the best in the 1 2 1 country and two of the strongest -- one of the strongest -- 3 RMPs and B agencies. 4 DR. MARGULIES: Is there any other comment on this 5 issue? 6 DR. CANNON: I want to hear your comments on 7 Dr. Stone's first listing, those four things now, because 8 what is going to happen to this document of Dr. Stonels? 9 MR. OGDEN: I wonder, Dr. Cannon, if we could 10 hold that discussion until a little later and try to finish 11 the agenda because I think a great many of us have comments 12 and discussion we would like to raise about this. DR. MARGULIES: Is that all right with you, 14 Bland? 15 DR. CANNON: Well, the only reason I mentioned it 16 here was that it seemed to apply to the bi-state problem, 17 and this is the reason I brought it up. I will be glad to 18 defer it until later. 19 DR. MARGULIES: On that articular point as to p 20@ what is going to happen with it, the document that you have 21 represents a presentation which was made to the council, 22 It provides them with information from the administrator. 2,3 The way in which the council responds, of course, depends 24 upon its judgm6nt. 25 I don't know what the implications are regarding 37 jon3 the geopolitical boundaries of regional medical programs 2 and if there is some doubt about it or if the issue needs to 3 be raised and clarified from the point of view of the 4 council I think it is quite appropriate that the council act 5 in whatever way it thinks it should. 6 There is only one problem involved in it and I 7 think that is why we should wait for further discussion. 8 That is that this is no longer a part of the public agenda. 9 As a consequence, any action of an advisory 10 kind which affects policy cannot be taken by the council at 11 this time but we can set up some other mechanisms to make ti what we do appropriate to the existing laws. We can get back to this discussion and then 14 perhaps set up an executive group or something of that kind 15 to do whatever you think needs to be done. 16 If that is all right we can go on with the reviews 17 and then come back to this discussion. It won't be long 18 because we have very little else that we need to take 19 review action on. 20 are to be DR. PAHL: The remaining applications 21 found under the pink tab At the back of your loose leaf book 22 and they are three applications which are requesting support 23 under our 901 authority. 24 Two of them are somewhat similar in nature and 25 have been assigned to Mrs. Mars and Mr. Ogden and the third I NoTit.-DO NOT USE THIS ROUTE SLIP TO DATE SHOW FORMAL CLEARANCES OR APPROVALS TO: AGENCY BLDG. ROOM 0 APPROVAL REVIEW Cj PER CONVERSATION 0 SIGNATURE rl NOTE AND SEE ME El AS REQUESTED El COMMENT (:] NOTE AND RETURN Ej NECESSARY ACTION El FOR YOUR INFORMATION 0 PREPARE REPLY FOR SIGNATURE OF REMARKS: (Fold here for return) ---------------------------- From PHONE BUILDING ROOM Fonm HEW-30 Rri. II/% ROUTE SLIP GFO:Igm-0-4@ 38 j on4 I one is a specific kidney application that has been assigned 2 to Dr. Merrill and Dr. Musser. 3 Before going into these, though, I would like to 4 make two remarks. The first is that in the case of the 5 applications from the southeast interregional program an 6 the northeast interregional program we do not believe it 7 necessary for council members to leave the room because of 8 conflict of interest because in these particular applications 9 it is treating an administrative matter and we believe this 10 conflict of interest can be waived. However, in the case with the kidney application 12 from New York, we will ask Dr. Watkins to absent himself from the room. 14 Also, I think to have a proper introduction to 15 these applications we would like to have.Dr. Margulies give you 3ust a,few words since this will be a new type of 17 application coming before the council. DR. MARGULIES: As we said earlier in the meeting, 19@ we have not completed the detailed description of how the 20 516 applications Are to be carried right now, but we are 21 able to act on a pro tem basis and have, As I think you know, 22 utilized the 910 section in the past in providing various 23 ranges of grant s. 24 What is being considered today in the first two 25 applications, particularly in the first one, is an affirmaticn j on5 3 9 by a proper procedure of some@hing which has been under way 2 for a long period of time on an informal basis. 3 The southeast coordinators have had as a general 4 agreement among them a sum of money which they utilize to 5 employ an individual who acts in the common interest of the 6 southeast coordinators. He coordinates their inter-program 7 interests, provides meeting arrangements for them, develops 8 programs and in general serves the southeast interests which 9 are of special interest to them. This is ranged over a very wide number o subjects. 1 2 This particular sectional grouping has begun to 'L3 grow and it has begun to show some real promise. It has had 14 a varying kind of streng th, but for the last few years the 15 regional medical programs have recognized the fact that there 16 are somethings which they can do, acting together, and the 17 e aphic regional basis which enhanced their common 9 09r., - 18 interest. 1,9 They, among other things, select from the various 20 geographic sections a representative to a steering committee 21 with which we meet regularly, providing us with an opportunity 22 to hear from them and to provide information to them in a 23 rapid and informal manner and to develop a kind of network of 24 information which is remarkable. We can, if we need to, get a question out an an jon6 4 0 answer back from all 56 regional medical programs sometimes 2 from the areas in a period of less than 24 hours which is 3 unusual for the federal government. 4 This sometimes provides us with some distinct 5 advantages in tight negotiations. Beyond that, it provides 6 an opportunity for them to gain a level of understanding 7 which is more explicit than you can sometimes achieve by 1 8 1 i waiting for formalized documents. 9 The southeast group has had in their employ 10 Mr. Youngerman for a period of, I would imagine, in excess 11 of two years. 1.2 In reviewing the arrangement that they had for 13 1 his employ it appeared to us th t this should be fo alized a rm 14 in the form of a 910 application so that there is a clear 1,5 understanding of what he is there for, what the funds are to l@6 be used for and a way of handling it in a grant administration 17 manner which is appropriate to the circumstances. 18 This will be the first one which we will be 19 acting on. The other one is to consider a similar arrangement. 20 in the northeast, but they have not actually experienced 21 having an individual in office up to the present timei 22 They understand what they want to do, but they 23 haven't had the arrangement that the southeast has had. 24 I think that is All. 25 DR. PAHL: All right. Why don't we turn to the 41 jon7 l@ southeast application and have Mr. Ogden present it and 2 Mrs. Mars as backup reviewer. xxxxx 3 MR. OGDEN: I am sure that all of you have had a 4 chance to read the material that was sent out, but be ore 5 reaching a conclusion on the advisability of funding it 6 I felt there was a series of questions that we should ask 7 and answer to ourselves. Some of them may be questions 8 raised out of my own lack of knowledge of relationships which 9 may exist, and if that is true I apologize for using the 10 council's time for my own education. But 1 have written down a series of questions 12 which seem to me to be pertinent to this type of an applica- 13 @tion and I would hope that we can answer them rather rapidly. 14 f'rst question was this: would this proposal My 1 15 duplicate the functions of RMPS staff? 6 I think the answer to that, obviously,, is that 17 ,there is no@one on'the staff doing this precise job. .18 DR. MARGULIES: I think that is correct. 19 MR. OGDEN: Then, should this be an activity of 20 the coordinators, or should it be an activity of RMPS? 21 Where will this man receive better control and 22 direc tion among the coordinators which is a loosely 23 organized group, or from RMPS? 24 Should the activity -- well, that is all right. 25 I was going to say if it duplicates an already existing 4 2 jon8 activity, should this be terminated, but this is beside the 2 point now. 3 How would this individual here contemplated and, 4 of course, is he already on the job, so perhaps that has 5 been worked out, but how would he relate to the RMP staff 6 people in the offices of Regions 3, 4, 5 and 6? 7 How does he relate to the operations branch of 8 RMPS once he becomes something more formal than he is. 9 Now, if these questions can be easily answered 10 having been thought through in the development of this application, then I would recommend the three-year funding 1 2 @l for this. That is, with annual reports to the council on 13 its progress and accomplishments, but I would like to have 14 some discussion from those who were more knowledgeable than 15 I about the relationship that the individual now has. 16 I know Mr. Youngermanl and have worked with him 17 on one or two things. I want to know the relationship he 18 has directly with the RMP staff people within the offices 19 of Regions 3i 4, 5 and 6, and how you relate to the operations 20 branch, what sort of more formal relationships would be 21 important and necessary. 22 Miss Silsbee wrote me there was about a two and 23 a half inch backup file on this which fortunately nobody sent 24 me. I am sorry that I have not had the opportunity to review 25 that because scim of these questions might have been answered in it. .nd4 4 3 cR 7535 take 5 DR. MARGULIES: I think that one could reasonably dor 1 2 say, Mr. Ogden, that there would be good reason to meet 3 that southeast area need for somebody to coordinate their 4 activities by somebody supported by RMPS, who is located 5 there and who has a responsibility to RMPS as well as to 6 them. 7 As a practical matter, it can't be done. We 8 don't have those kinds of resources, and the staff is 9 being nibbled at, rather than otherwise. 10 on the other hand, there is a different kind 11 of generation of interest in having him, because he repre- 12 sents their choice of someone to work with them for interests E 13@ that they identify in common. 14 I.know that he has been of great assistance.to 15 them in organ zing major meetings on such issues as regional 16 kidney dialysis and transplant activities, quality assess- 17 merit,.and assurance, which they address together in the 18 Southeast group, and he has certainly had a hand in making 19 the sectional meetings in the Southeast clearly better 20 than they are in any other part of the country. 21 He can develop an agenda for them, find out 22 what their common interests are and produces a sense of 23 commonality in bringing them together that couldn't be 24 produced otherwise. 25 Again, this could be accomplished by people 44 dor 2 1 operating out of our staff, but that is a remote possibility. 2 There is the possibility that an individual 3 placed in that position will become not merely a coordinator 4 of activities, but something more aggressive, a spokesman 5 for them, going from a level of mild interest to an aggressive 6 interest and beyond, and I think that it is very important 7 that it be understood that he serves the interests of 8 the coordinators locally in terms of their professional 9 and organizational concerns as Regional Medical Programs, 10 and does not concern himself there or anywhere else with 11 such issues as those that might a pear to be lobbying p 12 activities or something of a similar kind. 13 I think that would be highly inappropriate with 14 the use of RMP grant funds and probably inappropriate under 15 other circumstances as well. 16 I think perhaps, Lee, you may want to comment 17 on this. 18 MR. OGDEN: I would like to know how he relates 19 now to the RMPS people in the reginal offices. 20 MR. VAN WINKLE: I can't speak for all the regional 21 Offices. I know that he and the Atlanta REgional Office 22 work hand in hand and most of their programs are planned 23 together. As far as staff, he keeps us fully informed. 24 He has been very supportive, and I would say that from his 25 base, he could be much more flexible than we could on staff. 4 5 dor 3 I think he is able to do things we are not, 2 and working with the RMPS. 3 DR. MARGULIES: Dr. Schreiner? 4 DR. SCHREINER: I have two questions. Although 5 I admire the success with which this particular individual 6 has worked, particularly in the kidney area, I think there 7 are a couple of bothersome questions. one is, does this 8 give this gropu of regions unfair advantage in a granting 9 program where there is rapidly shifting directives, and 10 rapidly shifting goals and constantly changing horizons. 11 obviously, if one group of regions has an incite into the 12 communications.mechanism that other groups don't. that p 13 bothers me a little bit, and the second thing is that the .14 biggest criticism against the RMP.is the excessive layering 15 between the consumer and the staff, and isn't this yet 16 another layer? 17 DR. PAHL: May I respond to the first question 18 concerning the advantage which accrues to this particular 1 9 region? 20 It is true that at the present time there is this 21 advantage to the one region in that the individual has been 22 operating there for perhaps two years. The fact that we 23 have an application from another region indicates there 24 interest in having this type of position available to them, 25 and we would presume that there could be over a relatively I 46 dor 4 I- short period of time five such individuals corresponding 2 to the five regions, five multi-regional units that the 3 coordinators themselves have defined. So that it is quite 4 possible we would have a total of five such positions with 5 two applications forlhese positions b efore us today. 6 Relative to the layering between RMP and the 7 consumer, I believe it is fair to say that this does not 8 represent layering, that this individual is working with and 9 among the coordinators on a professional basis, and that he 10 does not interpose himself, either as the individual or the Position, that is not interposed between the Regional 12 Medical Program and the consumers and clientele and others. 13 Harold, do you want to comment on that point? 14 DR. MARGULIES: Dr. Brennan? 15 DR. BRENNAN: I have already said this about it 16 going to five, I was going to remark that it would robably p 17 go to five, plus I am sure a couple of secretaries and an 18 administrative assistant, and some office space, and a 19 heck of a lot of travel money, eventually, and I think this 20 is going to add to the administrative costs of this program 2 1 substantially. 22 I think you can't do this without realizing what 23 Dr. Schreiner was implying, that you have created a new 24 rank and office, and now to talk about supporting that out 25 of 910 funds, I wouldn't think that 910 funds would be the 4 7 1 1 appropriate place to get this. I don't think this is an dor 5 2 inter-regional program activity, or developmental activity, 3 per se. I think this is clearly an administrative assistant 4 to the coordinator. I think if it is going to come from 5 anywhere, it ought to come out of our RMPS administrative 6 budget, but not without the realization that we are not 7 talking about only one fellow, we are talking about five 8 people, and by the time you get through, you will have 9 assistants for each of those guys. 10 MR. OGDEN: Mike, might I comment here that yesterday, we had Dr. Milliken reporting on the problem 12 that developed among the Mountain States programs, and I 13 had the feeling that had there been this type of man around, 14 that roblem might have been avoided. p 15 And I can see some real benefit from having 16 someone like this. 17 I think the question you riase as to what 910 18 funds are intended for and whether this is the proper use 19 of them is something that we ought really to perhaps discuss 20 a little further before we vote on this. 21 I am not sure that I understand precisely what 22 the 910 funds are permitted to be used for, whether we can 23 use them for this type of personnel or whether it is 9@4 something limited to a grant which is sort of run through 25 and has been approved by a cooperative arrangement between 48 dor 6 1 two Regional Medical Programs. So it would be br a grant 2 purpose rather than a personnel purpose. 3 DR. MARGULIES: This is appropriate for the 910, 4 which has a fairly broad description, but it does meet the 5 requirement of achieving on an intet-RMP basis something 6 which cannot be accomplished by the individual RMP and 7 which is a common concern. In this case, it is to provide 8 a framework within which the professional achievement of 9 the combined RMPs can prosper. I think Dr. Brennan's point 10 is perfectly valid. 1.1 It would be a good thing if we provided this 12 support out of administrative funds. 13 If you look at the record with Federal employment 14 -in general and RMPS specifically, we are in 1972 approximately 115 at,one third of the level of employment we were three years 16 ago, and the present staff level has been reduced during the 17 past year below the official level, which was budgeted, 18 because there have to be people placed in other kinds of 19 activities, so that we are more likely to have fewer people 20 available in the future than more. 21 So the question of whether this should be done 22 by RMPS placing people there is a reasonable one, but not 23 a practical one. There isn't a chance that we would be 24 able to do it. 25 Mrs. Wyckoff? 4 9 dor 7 MRS. WYCKOFF: If he is on the central staff, 2 they certainly wouldn't have that feeling. But if he is 3 under 910, they might feel that they really did have their 4 own man. 5 DR. MARGULIES: The decision is theirs, the 6 employment is theirs, the management is theirs, the super- 7 vision and hiring and firing is theirs. 8 Dr. Brennan? 9 DR. BRENNAN: You know, if this kind of adminis- 10 trative facilitative function, which is what I think it ist 11 it is a coordinating facilitative function that belongs 12 properly with administration, if that can't be differentiated from 910 money, then theoretically, the whole administration 13 14 here in Washington could be paid for here with 910 money. 15 There has-to.be a chord there, and we haven't struck 16 on it in our discussion this morning. 17 if this man is this important to the regions, 18 and after all, it is one manis salary here, you have got 19 five regions. I can't imagine any of them going broke by 20 putting in two or three thousand each with the approval 21 of their regional advisory gorups to provide this man and 22 his office and travel time. 23 MR. OGDEN: That is exactly what they are doing 24 right now. 25 DR. BRENNAN: But that is what I would like them 50 dor 8 1 to continue doing. My own idea through the years of the 2 910 funds has been something different. It has related 3 to such things as the provision of educational materials, 4 because the thing could be done better for multiple regions, or more economically, or sensibly than trying to 5 6 set up the same operation in all regions. I think inter-regional cooperation in Some areas 7 8 is absolutely right and functional. 9 I think that is where 910 money should be, and if what these coordinators need is this kind of help to 10 11 do a better job, then let them continue to make an invest- 12 ment in it. 13 DR. MARGULIES: That is precisely the thing they have to do, and you are talking about the same moneyl 14 Mike, whether they do it invidiually or through a mechanism. 15 16 It is the same pot of money, but it has been done in an 17 irregular fashion, because the are diverting grant fun s y 18 into an activity which should be recognized by this council, 19 and either you accept the idea, or you don't, and if you 20 accept it, the only mechanism available is 910, because it 21 covers the inter-regional program activities. 22 You cannot give them oney for aid programs or a series of them, and then take X amount of that to support the 23 24 activity without circumventing the grant process which is 25 being utilized. I 51 dor 9 It is a way of looking at it and deciding whether 2 that is what you want to have done or not. It is all the 3 same money. 4 DR. BRENNAN: What I was saying, Harold, was 5 this, I think if the reginal advisory groups in all five regions had to continuously reindorse on an annual basis 6 7 the continuance of that function, that it is going to get 8 a local evaluation that will be a little wider than just whether the coordinators feel this guy is useful. 9 10 Taking it into 910 might not allow for that. I 11 don't see why this would be a legitimate expense out of what we used to call core staff, or even developmental funds or 12 our regional advisory group to authorize, to pool in, to 13 help get such a fellow. 14 DR. SCHREINER: There are all kinds of arqaniza- 16 tions@ that don't have regional chiefs, and when they need 17 to communicate with each other, they have a meeting, or 18 elect a committee, or they vote one of them to perform 19 the communication. It seems to me to be an administrative 20 thing, and I think we are open to criticism, as Mike says, 21 if we really haven't done much with 910 funds in an imagina- 22 tive or ingenious way, and the very first thing we think 23 of doing is to hire another administrator, that just doesn't )@ excite me. 25 DR. MARGULIES: We have used the 910 funds to I I dor 10 52 1 support several millions of dollars worth of activities, all 2 the emergency medical activities and the health services 3 in the past year and the cancer center in Seattle, where 4 it was 910 funds. It seems to me you are playing around 51 @.With the qu6stion of whether you think this is a good idea 6 or not, because if you knew, there is a proper way to do it. 7 Up to the present time, this has been going on, 8 and it has been hidden from you because it has been 9 supported by taking part of grant funds from the individual 10 programs to provide payment for him. 11 This simply pulls it out in the open and lets 12 you decide whether it is something you would 13ke to see 13 supported or not. 14 DR. PAHL: Mrs. Mars, I don't believe we have 15 heard from you. end 5 16 17 18 19 20 21 22 23 24 25 53 7535 # 6 MRS. MARS: Before we make any decision on the 21 Reba 1 Southeast, I feel that the presentation should be made of 3 the Northeast application, because the stated objectives 4 and reasons are sited in both, and I don't think it is quite 5 fair to thoroughly discuss one without considering the other. 6 DR. PAHL: Would you please proceed to present 7 the Northeast? xx 8 MRS. MARS: If I could, I would go ahead and then 9 let the discussion be continued, because whatever decision 10 is made on one certainly sots an example and influences what must be said about the other. 12 Of course, the Southeast does have the 3 and a half years experience in sponsoring this program, as we have 14 already stated, and it certainly has provided some excellent l@5 results, and it has allowed them to move more rapidly, cer- 16 tainl on an inter-regional basis, into new areas of interest. 17 1 am well aware of this, because I am from Virginia, 18 and Virginia is part of the southeast. Now the proposal that 19 Northeast is presenting is the result of a joint decision 20 which was reached at the September 14th meeting of the North- 21 east Coordinator's group. 22 This group constitutes 15 regiong, and they 23 voted unanimously to authorize submission of this 910 appli- 24 cation. 25 The application is submitted on behalf of a group 54 6 by the Greater Delaware Valley RMP, which has agreed to Reba 2 2 act as the host region. 3 They wish to employ a full time staff person whose assignment would be to force interregional activities, 4 5 improve the coordination of similar endeavors, and in communi- 6 cations problems, experiences and opportunities which require 7 interregional attention. 8 I personally can see many advantages in having 9 such a person. Certainly it would facilitate a more rapid 10 exchange of information among all the members of t e group about their individual activities as well as about the federal trends and programs, and certainly going to the south- 1,3 east program, this is what Mr. Youngetman has functioned and done in our own Virginia program. 14 15 The position would be financed through the 16 910 grant from RMP at a salary of $26,000 a year, plus 17 $3,120 in benefits. One secretary would be employed at 1-8 $7,000 a year with $840 benefits. 19 The office would be placed at the Univ6ksity 20 Science Center, which is the grantee institution of the 21 greater Delaware Valley RMP. 22 The total budget request for 3 years is $217,678. 2,3 For the first period, $71,329, for the second period, $71,583, ahd,fok the third period $74,766. 24 25 This includes salary, travel, which Dr. Br6nnan 55 6 l@ brought up, at an average of $10,500 per year. The office Reba 3 2 space, $2,000 per year, equipment and communications. The 3 equipment, Of course, would come, really, in the first year. 4 I think it appears to be a fairly reasonable 5 request, and certainly not excessive. 6 The Chairman of the Northeast RMP coordinator 7 group, who is also the director of the New Jersey RMP, by 8 name Dr. Alvin Florin,has received letters with varying 9 degrees of enthusiasm supporting and endorsing, from the 10 directors of the 15 RMP's w-ich are Nassau-Suffolk New Jersey, 11 @New England, Rochester, Susquehanna Valley, Western Penhsyl- 12 i@vania, Albany, Central New York, Connecticut, Greater Dola- 13 !ware Valley, @'@-the States Area, Maine and New Jersey. I 14 The liaison committee of the coordinators group i5 will hire and supervise and direct the programmatic adti Vities 16 of the representative and in accordance with the objectives 1-7 established by the group. The coordinator and grantee 18 institutions of the host RMP will be responsible for the 19 administrative supervision of the administrator, so the 20 supervisory controls are well set up. 21 Personally, I would like to see this funded 22 provisionally for two years only, with support guranteed 23 for the third year if it can be shown at the end of that time 24 that there is an outstanding advancement in the northeast 2,5 region's effectiveness, its.-. programs And its impact on the 5 6 6 @l problems thereof. Reba 4 2@ I do not feel we can recommend funding for one 3 year. Certainly no individual of the desired quality would be 4 willing to take such a position for only one year. And 5 especially in the light of the high standards that have been 6 established in the job description that they have presented. 7 So I visualize this, really, as an aid in solving 8 problems of regional overlap, geophysical problems, and 9 preventing situations and helping to resolve them, such as 10 we have heard about so much in the last day, as between bi-state 11 and Illinois. 1.2 I think if such an organization and such a group Ihad existed, many of these can be resolved. So that I think 14 it is a tool that can be used to great advantage by the 1.5 regions, and if we do approve this, of course, we are estab- 16 lishing a prototype which I feel personally can become a 17 very useful thing.@ 18 So in order to facilitate more discussion, I move 19 we approve the northeastL910 application, but with a recommen- 20, dati@on that it be done for a two-year period of funding with 21 a third year of 'funding guaranteed if after assessment at 22 the end of that time, it appears justified by outstanding 23 program achievement in the region. 24 DR. MARGULIES: I wonder if we could hold our motion 25 Eor the moment and go back to the previous one, which is still I 57 6 Reba 5 i@ on the table. nflict in it, that 2 MR. OGDEN: We have a modest co 3 I have said in the questions I had raised which were answered 4 and were things which we could discuss and have conclusions 5 about, that I would recommend a 3 year funding for southeast 6 with annual reports to the council now on the progress and 7 accomplishments of this. 8 So I would think if we are going to fund Sout east 9 for 3, we ought to do Northeast for 3 at the same time. 10 Now we have been passing some notes back and I.I. forth across the table down here, and we have come to the 12 conclusion if there were about five of these, this could run 13 to about half a million dollars a year throughout the United 14 States, So we are not talking about a significant amoun 1-6 of money. my own reaction to this is that this is a worth- 17 while expenditure. I recognize the fact that this is a 18 new precedent in the use of 910 money, and I would suggest 19 that if we approve this we do it on the understanding that 20 we are going to have one man in an area, a group of regions 21 doing this, and that we don't know begin to have a 910 22 application for somebody to coordinate kidney and heart 23 disease and stroke and cancer, and a proliferation of 24 activities. 25 DR. SCHREINERZ These five fellows are going to 58 6 Reba 6 1 establish a liaison, and then want an office to coordinate 2 that. 3 DR, OGDEN: Let's don't start a parade of horrors. 4 That is a legal argument, and I have used it many times. 5 Let's dross that bridge when we get to it. The thing that 6 concerns me at the moment is that we would want to see someone 7 coordinate kidney, or something of this nature, and I would 8 suggest that we settle with the understanding that there is 9 going to be one man involved in this kind of thing. 10 MR. PAHL: Dr. Komaroff? 1-1. DR. KOMAROFF: You said it is all the same pot of money, but as I see it, although funds are small, you are @13 really saying that tome supplemental money, on the order of 14 $3 to $5 thousand per region, should go into the administrative 15 part of the total RMP expenditures. 16 They are now doing this. They are now supporting 17 this man, and this gives a supplement of a small amount, l@8 about $5,000 per region, for core administrative support, 19 and I wonder whether Mike's point isn't the most telling. 20 I am also bothered by using 910 funds for a non-opetational 21 purpose, but this is just another and perhaps very valuable 22 administrative mechanism. 23 If it is that valuable, the regions themselves 24 will demonstrate their faith in its value by using their 25 existing administrative funds to support it, as they have 59 #6 Reba 7 j- and --- 2 DR. OGDEN: I don't feel an objection to the use 3 of 910 funds for administrative purposes if it is going to 0 4 do a real job of coordinating the grant activities in the 5 regions. 6 DR. MARGULIES: Since the funds are now being 7 utilized out of existing grants, this would merely mean that 8 the same amount of money would be used for this purpose. it 9 would not add this amount and leave in their grants what io they have been using. uld be keeping it at the same level. It wo OGDEN: to a point here, and without DR. To get us aning to cut off further discussion, I am going to move, me 14 if it is appropriate that both Southeast and North6ast 15 then be funded for a 3 year period with annual reports to the 16 Council on the progress. 17 DR. MCPHEDRAN: You mean this won't increase th-e 18 Administrative costs? 19 DR. MAAGULIES: Well, it would increase the Northeast, because they are not paying for this kind of 21 individual, but in the Southeast they are alread paying for y 22 it. 23 MRS. MARS: They Are using money which could be, 4 used for programming. 25 DR. MARGULIES: Could we have a second to th3"s? 60 6 Reba 8 1 MRS. MORGAN: I second it. 2 DR. PAHL; Is there further discussion? 3 Dr. Brennan? 4 DR. BRENNAN: I think that it is important for us 5 to remember that we are probably facing a considerable re- 6 duction in the availability of funds for RMP activities 7 generally next year. The 910 funds are our chief hope for 8 being able to move out promptly into the control activities 9 which we have been advised we had best learn how to include 10 here in a stronger way, in Mr. Stone's statement yesterday, 'I I and in other sources. 12 1 think that the half million that we can and 13 up getting into this new layer of administrative work, if we 14 look across the country, it will run us something on the order I'D of half a million a year. That may be perhaps far better l(i spent in other ways4 17 Furthermore, I think it is the duty of these 18 coordinators, and a requirement of their job that they communi- 19 cate with their neighbors and that they sustain these pro- 20 grams, and I honestly don't believe that we have to add this 21 kind of administrative level. 22 What with all of the means we have, thatis true. 23 RMP staff isn't as large as it was, But what are we doing? ),4 Are we circumventing administrative$ an attempt to keep down 25 the proliferation of administrative activities in these 61 6 Reba 9 programs by going around a directive that says "no more 2 administrative help to be hired" and taking from grant 3 operations for the purpose of an expansion of this kind? 4 DR. PAHL: Mrs. Wyckoff? 5 MRS. WYCKOFF: It is very plain to me that 6 coordinators and people from the different RMP's seem to 7 learn a great deal from each other. They enjoy the direct 8 communication over the back fence, comparing notes and how 9 does it work in your area, much more than they do going UP- 10 I stairs and communicating with a higher level, and I think 11 this thing has some great value in oiling the wheels between the coordinators. end 6 14 17 18 19 20 21 22 23 24 25 CR 7535 62 # 7 1 DR. MARGULIES: I think before you vote on this, kar 12 you should realize that -- I don't know any way of putting it 3 without appearing to influence youi and I am trying not to, 4 but if you vote against it, then we will'have'to instruct 5 Southeast to discontinue the employment of the individual 6 who is there, because the principle remains the same. 7 This is money which is being used out of grant 8 funds to support an activity. 9 DR. KOMAROFF: I think there is a difference. DR. MARGULIES-. They cannot do it legally the way it is being done at the present time. DR. KOMAROFF:L Let me suggest that it may be true 1,3 that the Southeast group who already has such a person, if you 14 award them the $53,000 in the 901 funds, you deplete each of (:@7 their other awards not made out of 910 funds accordingly. 16 That threatens not to be the case in the Northeast group and 17 the potentia@ Western group and the others. If we could be 18 assured that agroup of regions that chose to use th s 19 mechanism and to fund it this way. would, in a sense, sacrifice 20 their non-910 and core support, it would make me .@live easier 21 with it. Conceptually, it may be a great thing- The Sout east 22 group has obviously made that judgment. 23 MRS. MARS: We are destroying it if we vote against 24 it. 25 DR. KOMAROFF: I am not.suggesting we vote against b i kar 2i it, only that we have administrative assurance that it won't 1 2 become extra administrative money in each region. 3 DR. SCHREINER: I have to disagree with that, Mrs. 4 Mars, because you are flaunting Parkinson's law. We have 5 southern governors conference and all kinds of people who 6 meet together on an inter-regional basis and elect a president 7 or a vice-president, and this is part of their job. 8 You don't need somebody, if there is a natural 9 desire to band together for a five multi-r6qional- program? 10 you don't need something to tell them that. If they are pros, they are supposed to be doing their job. But they have 1-2 authorization and have travel funds. They have authorizations 3 to have meetings. They can bring administrative staff in. 14 I think what you are really doing is, you are going to have 15@ them regress, because you are saying "Okay, now, don't do this 110' for yourself, we are going to have another fellow do it for 17 you, " and it is not voting against the idea. It is voting 18 against the proliferation of administration which sometimes 19 paralyzes ideas. 20 MRS. MARS: Someone has to coordinate, though, and 2' be chairman. 22 DR. SCHREINER: That takes an election. 23 MRS. MARS: But the coordinator in the Northeast 24 case who has been made chairman of the group has found that it 25 is just too much of a burden. He is neglecting his other work 6 4 kar 3 1 in attempting to coordinate work between the regions, and for 2 each of them to be able to understand what is going on in 3 another region. This would be a help to him, just as it has 4 been in the Sottheastern group for all of us to benefit from 5 what is going on in the other regions, whereas it is not taking 6 time,laway from,the coordinator who should be spending time in 7 his region. @8 There are only 24 hours in a day, and a man can't 9 travel between 15 regions. None of them can. 10 DR. PAHL: Mr. Merrill had the floor. 11 DR. MERRILL: I just wanted to be sure of one point. 1-2 Am I correct in understanding if we were to vote against if funding this particular individual from 910 funds that his 14 position would no longer be tenable because his funding as it 15 is now carried out is illegal? 16 MRS. MARS: That is correct. 17 DR. MARGULIES: That is correct, and furthermore, 18 the question is really one of the principle of whether funds 19 which are available for grant-,purposes should be used as this 2 0 discussion has indicated, yea or nay. 2 1 DR. PAHL: Dr. Brennan? 22 DR. BRENNAN: I think we are now in a position 23 where if we are talking about a principle, whether or not ?@4 grant funds should be used in such and such a way, we are 25 clearly talking politics. We are not just talking About two 6 5 kar 4 1 grant applications, and if that is where we are, we are in this 2 session not able to make such policy. 3 DR. MARGULIES: It is impossible, Mike, to distinguis 4 on a grant application the difference between forming a policy 5 and acting on policy. I think in this particular case you 6 are acting on policy. 7 DR. BRENNAN: I think the character of this dis- 8 ctssion shows the group is seeking for-'some kind of a policy 91,@ position, but regardless of that, it is inconceivable to me @10 @that these five regional medical programs could not find some 11 way legally to hire this man. 12 if one of the programs decided to hire him as part lof his core staff and simply assigned him to this duty in the 14 interest of the good of the program, I don't see howwe could 15 say that that was illegal. 16 DR. MARGULIES: Would you approve that? 17 DR. BRENNAN: Why, good Lord 18 DR. MARGULIES: What is the point of distinction' 19 between doing that, and the magic you are applying to 910. 20 It is all the same money. 21 DR. BRENNAN: But there is a different control 22 Ifactor. 23 DR. KOMAROFF: That is part of it, and with the 24 Northeast group, this appears to be $70,000 split up 15 ways 25 to these regions. We are talking about extra administrative 6 6 kar 5 1 support, it,seems. although with regard to Southeast, there is 2 the assurance that the total level of the Administrative costs 3 won't go up. Why don't the other regions contract out to 4 Georgia for the services of such a person? 5 DR. MARGULIES: You have to quit playing with this,, 6 issue. Either you don't believe the issue, or you do, and 7 that is what you are voting on. 8!, DR. BRENNAN: You are giving us a false position. 9 We refuse to be put in the position of saying that because we 10 oppose this, we oppose coordination. 11 DR. MARGULIES: You are talking about whether a man 1.2 should be hired with secretary and supporting staff with grant funds, and inthis case in order to do it, you have to use 910. 14 That is the issue. 15 DR. KOMAROFF: It is extra money, as well as 910. 16 DR. BRENNAN: Harold, would you tell me categorically 17 that it would be illegal for Georgia or someone else to hire 18 the man and pay his salary And assign him to this function? 19 DR. MARGULIES- Yes. That should be covered under 20 910. 21 DR. BRENNAN: It would be illegal? 22 DR. MARGULIES: It is improper use of grant funds. 23 If the,Council wants to approve the use of funds for that 24 purpose, it will have to go through 910. And if it is going 25 to be done, the Council should approve it. I I 6 7 MR. OGDEN: I move the approval of the two pro- kar 6 2 posals. 3 MRS. MARS: I still would like to say that I think 4 that Northeast should not be funded for more than two years 5 with a guarantee of the third year, because it is an experiment. 6 Southeast has had three and a half years experience, and they 7 know what they are doing. The Northeast may not be capable of 8 carrying out such a procedure. 9 DR. MARGULIES: Do you accept that change? MR. OGDEN: Three years for Southeast, and two fo?V 11 Northeast. l@2 MRS. MARS: With that third year guarante 13 MRS. MORGAN: I second it. 14 DR. PAHL: Is the motion clearly understood by the 15 council? If so -- 16 MR. HIROTO: If we vote against this because the 17 funds are being used not according to guidelines, that the 18 Southeast project is basically illegal, and that Northeast -- 19 DR. MARGULIES: Jerry, do you want to comment on 20 that? 21 MR. GARDELL* I think the use of the term "illegal' 22 is probably one that should be pursued a little more from 23 this point of view. 24 The way the support of our Southeastern coordinator 25 is being budgeted is, I think, unacceptable. He is not shown 6 8 kar 71 in any category in any budget. In other words@, as Tony is 2 saying here, if you reduce -- if you support him under 910, 3 there is an automatic reduction to the grant. We can't 4 actually go but and find that money at the moment, because 5 none of the regions actually has a budget item for the support 6 for the individually collectively. 7 So it comes out of what we talked about as a kind 8 of a slush fund in the grants. 9 This is what we don't want to continue because I am afraid that should an auditor get out there And find there is sp6cifi6 support for an individual of this 'sort, there is 12 1 no budget item for it, he is performing service for a number of programs, I don't think we should continue in that vein. 14 I think that is what Dr. Margulies is trying to get Across 15 here. 16 DR. BRENNAN: Would your objections be overcome.!.if 17 a region agreed to hire this man and other regions prorate on 18 a line item in their RAG approved budgetse monies for this 19 function? What would be wrong with their doing this.? 20 MR. GARDELL: I don't think there would be anything 21 illegal about it, but I don't think we have approached it from 22 that point of view, and before I answer, I would like to 23 pursue it a little bit. 24 We are now developing informational people out in 25 the regions who are coordinating the activities, and their 6 9 kar 8' activities are being coordinated from here, and I would like 2 to take a look at the whole picture rather than an individual 3 a plicati6n like this, or one region supporting it, and p 4 obviously we haven't discussed it to that extent Around here 5 to raise all the pros and cons, but I think that might be 6 appropriate. 7 DR. PAHL: Dr. Merrill? 8 DRi MERRILL: I think we are really touching the 9 basic issue, and the same identical question has been asked 10 four times, reflecting the uncertainty of everybody concerned 11 about whether or nto it is legal or according to guidelines or not, and I am sure that in my own mind I asked the questior 1,@ first, that if I were sure that it could not be done any othey. 14 way, I would then vote for it, but I cannot really imagine 1,5 some legal way could not be found for doing it. 16 I wonder if there is any possibility that we defer 17 the vote on this until we do get a very clearcut policy 18 statement on it. 19 DR. MARGULIES: Would it help you any to hear the 20 language of the 910 section, which Mr. Baum can read for you? MR. BAUM: The actual language of the legislation 22 reads as follows: "Section 910A. To facilitate inter- 23 regional cooperation and develop improved national capability 24 for delivery of health services, the secretary is authorized 25 to utilize funds appropriated under this title to make giants 70 to public or nonprofit agencies or institutions, or combin- k@r 9 1 2 ations thereof, and to contract for (1) programs, services 3 and Activities of substantial use to two or more regional medical programs. 5 (2) Development, trial or demonstration of method,@ 6 or control of heart disease, cancer, stroke, kidney disease 7 or other related diseases. 8 (3) The collection and study of epidemiologic 9 data relating to any of the diseases referred to in paragraph 10 two. it (4) Development of training specifically repre- 12 l'i sented to the prevention, diagnosis, or treatment of any of the diseases referred to in paragraph two, or to the rehabili- 14 tation of persons suffering from any such diseases, and for 15 continuing programs of such training where shortages of 16 trained personnel would otherwise limit application of know- 17 ledge and skills important to the control of any such disease, 18 and 19 (5) The conduct of cooperative clinical field 20 trials. 21 (B) The secretary is authorized to assist in meeting 22 the costs of special projects or approving development of new 23 means for delivery of health services concerned about the 24 diseases with Which this title is concerned. 25 (C) The secretary fis authorized to support resear--h 7 1 kar fO studies investigations, training and demonstrations designed 2 to maximize the utilization of manpower and delivery of health 3 services.11 4 Tha t is the total thing. 5 DR. PAHL;:, Thank you. 6 DR. MARGULIES: Are you ready for a vote? 7 MR. OGDEN: Yes. 8 DR. MARGULIES: All those in favor, please raise 9 your hands. 10 (Hands raised.) DR. MARGULIES: Opposed? 1,2 (Hands raised.) 13 DR. MARGULIES: Letl§ do that again. 14 All those in favor please raise your hands. 1 5 Opposed? 1 6 It is carried. 1 7 DR. CANNON: What was the dount? 18 DR. MARGULIES: Seven to four. 19 I am sorry. It was seven to five. 20 MR. OGDEN: Do you want to do it again? 21 DR. MARGULIES: Let's do it again. Ten are for it. 2 2 I don't count very well. 23 Opposed? There are five opposed@. It is ten to fivB. 24 We can have a coffee break or go on, whichever 25 you prefer. I kar il We will adjourn for 15 minutes. 2 (Coffee break taken here.) E 3 4 5 6 7 8 9 10 l@2 13 14 15 16 1'7 18 19 20 21 22 23 4 25 CR7535 73 Al #8 jrb 1 DR4 DE BAKEY: If you will take your seats, please, 2 we will continue. 3 We have one 910 application to review, which should 4 not take long. This is a kidney application from the Metropolitan New York Area, and Dr. Hinman is going to 6 introduce it, and the discussion which follows will complete 7 the formal action on the 910 applications. xxxxxxxx 8 DR. HINMAN: This represents an application 9 submitted by the Metropolitan New York Regional Program as a 10 910 application covering New York, New Jeksey and the 11 assau-Suffolk RMP'. N ]@2 It is submitted by the Council of Blood Banks of New York Cit and the@object is to develop a multi-region @y 14 organizational procurement network with tissue-typing facility 15 -Lies. 16 The original application was for five years of 17 support with the first three years being level funding and 18 then showing a fourth and fifth year with some third patty 19 reimbursement for the organ procurement and tissue-typihg 20 activities. 21 A staff assistance visit was conducted in 22 September and the budget that is shown on the yellow sheet 23 was the one that was resubmitted after that. 24 This was reviewed in conformance with the kidney 25 guidelines by three outside technical reviewers. At the time I I 3rb 2 74 1. they were originally there, they expressed their basic 2 endorsement and support of the proposal. 3 Subsequent to that visit, some additional informa- 4 tion has come to light. The first of these things was that 5 we received an application from Downstate Medical School 6 for a transplantation and tissue-typing activity; and 7 Downstate Medical School was supposedly one of the active 8 participants in this 910 application. 9 This may have been engendered by the fact that 10 the new Chairman of the Department of Surg ery just arrived 11 October 1 at Downstate. 12 The second thing is that last Friday we received I 3 a letter from two of the transplant surgeons at Mont6fiore 14 withdrawing their support of this application. The Staff 15 is left at this moment with an application to do something 16 that is considered extremely worthwhile, but some question 17 as to whether the commitments expressed in the application 18 sent in in June and July are indeed the commitments of the 19 individuals in the region. 20 Staff also'still has some question about some of 21 the budgetary items, and I guess I will give it to you. 22 Dr. Merrill is the review now. I will give it to him 23 for conclusions. @?4 DR. MERRILL: Well, this is a problem with which 25 I am quite familiar, although the material on it arrived in 75 jrb3 l@ Boston about the time I landed in Mexico, but I think 2 I can comment on it. 3 Really, the problem is simply that if one is going 4 to have a regional typing laboratory for organ sharing, it 5 has to be truly regional, with a participation of, 6 obviously, more than one hospital, or even one big center. 7 The problem, as it is becoming more evident, is 8 that if one is going to set up a program for procuring 9 cadaver organs, the typing as it exists now makes it 10 absolutely necessary that it be a large program. 11 Therefore, with that in mind, if Downstate is 12 @l putting in a separate application and Montefiore has reser- 13 vations about whether they want to participate, it seems to me 14 that this is not yet in a stage where it can be of real help 1,5 in a true regional sense. 16 However, as Dr. Himan indicated, I think it is 17 essential that some kind of tissue-typing activity be kept 18 going, at least until the participants themselves can decide 19 on exactly what they want to do. 20 it may take the new chairman of Downstate a little 21 while to do that. With that in mind, and Dr. Musser has 22 read this -- he and I agree. It is, I think, the feeling of 23 all of us that we cannot recommend approval of the project @@4 at the present time, but that we do recommend that considera- 25 tion of the proposal be deferred pending a staff site visit jrb 4 76 I to study and evaluate and, hopefully, to reconcile the 2 uncertain aspects of it -- that is, the participation of 3 Montefiore and Downstate. 4 It is possible that the Blood Council Blood Banks 5 may run out of funds for their own endeavor between December 6 31 and the end of March, and with that in mind, since we 7 believe some sort of nucleus ought to be kept going on which 8 they can build, I would recommend and Dr. Musser agrees, that 9 the Director of RMP's should be authorized to provide interim 10 funding should he find such to be necessary. 11 DR. PAHL: Thank you, Dr. Merrill. 12 DR. SCHREINER: John, what are we going to do 13 about the Downstate application? 14 DR. HIMAN: The Downstate application has not gone through the mechanism and has not been reviewed by 16 RAG, so it is not really a valid application. It arrived 17 unsolicited,'and has not gone through any of the 18 appropriate mechanisms. 19 The 910 mechanism seems ideally suited to try 20 to assist the Metropolitan New York Area in the development 21 of its transplantation activities, and we hope, and we have 22 been in some discussion both at the Transplantation Society 23 and At the Kidney Consultant Meeting with some of the parti- 24 cipants in the total activity in New York City. We think we 25 can hopefully pull everything together to agree upon, one, jrb 5 77 1 a reliably neutral area; two, an appropriate technical 2 controlling advisory or policy-making group that is 3 appropriately recommended. 4 This is one of the issues that was raised, as to 5 whether there was an appropriate representation on the 6 proposed advisory committee to the councils blood banks; 7 and, three: that this will then, Montefiore will withdraw 8 its letter of withdrawal and go back to its original 9 commitment, and that now that the new chairman of the 10 department is at Downstate physically and starting to talk 11 with people that we can reconcile their concerns. 12 We are optimistic that we may be able to get a 13 single application out of this that will include the three 14 ma3or activities, the Cornell, the Downstate and the Einstein 15 activities. 16 DR. MERRILL: I think if you don't do something 17 like that, knowing the situation in New York, that you are 18 going to have utter chaos, because the problem is one of a 19 very energetic young man moving into an area which actually 20 has moved rather slowly to date, and it may well be that 21 downstate under these circumstances would be doing all of 22 the transplanting and tissue-typing. 23 I think that is probably not the way we would 24 like to see it go. 25 MS. SILSBEE6 I think it is important for the Icouncil to realize that there are other areas, New Jersey jrb 6 78 I and the Nassau-Suffolk. So any word that goes back with 2 regard to this action should be done in a way that would 3 enhance this cooperative effort rather than help to 4 bring it down. 5 DR. SCHREINER: This is the point I was about to 6 make, that anything we can do to support the staff on 7 this kind of a situation, and what I would hope would not 8 happen is that some isolated carrier would be funded in the 9 meanwhile, because it seems to me that there will be a 10 deterrent to trying to accomplish the larger goals. 11 I think we ought to do anything that we can 12 do to bolster the cooperative effort. 13 DE.,,--BAKE,Y: I think that is the intent, as 14 Dr. Himan has pointed out; and what we will do with this 15 not really application, but more a statement of intent at 16 the present time -- is go back and try to bring the people 17 together and have them do this as a regional issue. 18 DR. SCHREINER: So the best thing we should do 19 is turn this one down? 20 DR. HINMAN: Rather than a straight turn-down, 21 because -we want to encourage the regional activity, what we 22 would appreciate would be a motion to the effect that we 23 encourage the activities that have gone on, but because of 24 the question concerning commitment and budget that the 25 council defers action until its February meeting. 79 j rb7 I We would like it to be as encouraging as 2 possible, because the problems of Metropolitan New Yor 3 are overwhelming in many respectst and these tentat3ve steps 4 forward should be encouraged, rather than discouraged. 5 DR. MERRILL: Would you like a formal motion? DR. PAHL: Yes, please. DR. MERRILL: I would like to move that 8 sent applications are deferred, or consideration be A rred pending a staff site visit pefully to reconcile some of h -nv tain aspects of this .. . . . ...... ...... present application, and also if I may include this in the motion in the interim, the Director of RMPS should be 13 authorized to prov-i4e interim f. ridi-ncj,.-..,- ....he-.@iq such 14 necessary. 15 DR. MARGULIES: Is there a second? 16 DR. SCHREINER: Seconded. 17 DR. PAHL: The motion has been made and seconded. 18 Is there further discussion? 19 All in favor of the motion, lease say "aye". p 20 (Chorus of "ayes.") 21 DR. PAHL: Opposed? 22 (No response.) 23 DR. PAHL: The motion is carried. 24 Before we turn to the concluding business of 25 the meeting, let me indicate that immediately after this jrb 8 80 1 meeting, Mrs. Mars has stated she will be driving to the 2 Dulles Airport and can accommodate passengers, if you will 3 see her. 4 In the back of your book, under the blue tab, there 5 are four regions, California, Colorado, Wyoming, Georgia and 6 Maine, with some information -- for your information only. 7 No council action is required. 8 If there are questions from members of the council 9 about these materials, the staff will be glad to respond. 10 If there are not questions, perhaps we could go on 11 to a discussion of the statement presented yesterday by 12 Dr. Stone yesterday, which I understand several members of 13 the council would like to discuss. 14 DR. DE BAKEY: Mr. Ogden? 15 MR. OGDEN: Ladies and gentlemen, I think yester- 16 day this council received a very important statement presented 17 by Dr. Stone which, at that time, received very little comment-. 1-8 on it other than some questioning to him about a few parti- 19 culars of the statement. 20 But I think thathis remarkslave concerned some 21 of us, that it may portend changes in policy directions. 22 Perhaps it is a statement made to open the options 23 depending upon funding for RMP and the control programs to 24 which it refers. Yet, because it will be in the minutes, I 25 suspect that it will cause concern among our coordinators I j rb9 8 1 @l. and our RAG's who may see in it a further shift in emphasis 2 and activity. 3 As I see it, if RMP money is to be used for 4 control programs, this means a vast reduction in our 5 currently-committed funds, and a definite change in what we 6 have been planning to do. 7 I cannot believe that such a change would represent. 8 revenue sharing at its best, which is a term used in the stat(.@. 9 If control funds are awarded to the institutes 10 referred to and administered through RMP as supplements to 11 our activity, then that is perhaps another matter. 12 Also, Dr. Cannon raised a few moments ago a question 13 concerning a statement made that refe 14 medical programs as being limited to states or subregions ------- . ..... c@7 15 to states. 16 Inasmuch as I am Chairman of the Ihteradvisory 17 Group of Washington-Alaska Regional Medical Program, I am 18 concerned that perhaps a statement has been made here which 19 is historically not accurate, and is counter to 20 policy which this body has established. 21 I have a feeling that this statement needs review 22 in depth by this council, There is no doubt that none of us 23 NhAve a chance or have had a chance to do it within the last ?@4 24 hours since we received it. I think we will want to have @25 reaction from our coordinators, and from our director and jrb 10 82 i , from the staff. 2 I am going to suggest that many others here may have 3 comments if they wish to make them, but I am going to sugges 4 that after the budget becomes known, perhaps this should be 5 a special meeting of council to consider the course to follow 6 and to deal with the issues raised in Dr. Stone's presentation. 7 These will have to do with substnatial policy 8 matters before this council, and also with the policy which WE 9 have established on the duration of the funding and the 10 phasing out of projects, which also is touched on. Now olicy apparently can no longer be since p 12 made in closed meetings, as I understand it, it would not 13 be proper for us to make policy at this particular session; btt 14 I raise these things as a matter of concern, as a matter 15 of direction for the program, in the hope that it will 16 encourage all of us to dwell on this with the gravity with which 17 I think it deserves. 18 DR. MARGULIES: Thank you. Mr. Ogden. The statement 19 is open for general discussion. 20 I would like to respond by saying that I think thai. 2 1 is a highly appropriate idea. To consider any policy in a 22 vacuum is difficult. The implications become clearer as 23 we know what the funding will be. The statement emphasized 24 the relationship between the National Cancer Institute and 25 Heart and Lunch and Mental Health, and the regional medical I irb 11 83 1 programs, and there were some necessarily speculative 2 concepts there, because we don't know what the funding will 3 be. 4 It does make a difference whether you are talking 5 about one level or another. It makes a great difference when 6 you have to look at a policy and realizei as Mr. Ogden has 7 said, that it presents an option and the options become much 8 sharper when you know exactly how much money is available an 9 what the position of the coordinators and the other groups 10 may be on it. 11 So that I would be perfectly happy to carry the 12 message of another meeting of the council, preferably, I am 13 sure, with Dr. Wilson available to discu ss the policy impli- 14 cations, and certainly at a point where we know the budget. 15 I think prior to that time it becomes extremely 16 difficult to know what the policy means in terms of actual 17 RMP functions. 18 We will plan to do that. I would like to say one 19 other thing while the opportunity is here: 20 And unfortunately some of the members to whom it 21 would be addressed are not available, but it is a reasonable 22 time, excepting that they aren't here, to again call attention 23 to the fact that two members of the council have served the @?4 maximum period of time they can be on the National Advisory 25 Council, Or. Clark Millikan, and Dr. De Bakey. It is jrbl2 8 4 1 difficult to think of regional medical programs without 2 them, and the name of DeBakey has been associated with 3 RMP since the beginning. I pay respect to the Chair-, which 4 is vacant, but which has often been filled, and effectively, 5 and Clark Millikan's, which is virtually always filled. 6 He was called away for reasons beyond his control. 7 We never know what happens with members who 8 have completed a term and are available for others. If I say 9 anything nice, they may be back here, and I may have o 10 rectify what I said while you were here. 11 MS. WYCOFF: Except I think I can act in the voice 12 of the council in saying we deeply appreciate what these 13 members have added to the whole history of RMP, and 14 the deliberations of this council. 15 MR. MILLIKEN: I am asking impossible questions, 16 I guess, but some of us face within the next month or the 17 month in a half -- would it be possible to get any 18 further clarification of this new proposed policy that would 19 be helpful or at least give us not more than five directions 20 to go at onde? 21 DR. MARGULIES:. That is a very good question. @22 Are there other items of business? 23 (Laughter.) 24 DR. PAHL: If not, before we adjourn, I would 25 like to thank the members of the council, and our staff, I jrbl3 85 1 particularly Mrs. Handell and Katie Stevers, for making 2 the arrangements and keeping this running smoothly. 3 With that, we stand adjourned. 0 4 (Whereupon, at 11:25 a.m., 17 October 1972, #8 5 the hearing was adjourned.) 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25