I t@111111 @@lifink 1. i[ilitio@l@iliti 96* Transcript of Proceedings DEPARTMENT OF HEALTH9 EDUCATION, AND WELFARE 7 7@ I-, C@ T-, 11 7' Jan.uL@@--y 1972 ACE -FEDERAL REPORTERS, INC. OfficiaZ Reporter8 415 Second Street, N.E. Telephone: Wasilington, D. C. 20002 (Code 202) 547-6222 NATION-I"IIDE COVERAGE LB DFPAP,NIENT OF 1,T, AI,I'H, EDIJCATION AND WELFARE 4 2 - - - 3 REGIONAL MEDICAL PROCXR@IS SERVICE, 4 REVIEW COMMITITE 5 6 7 8 9 10 12 13 Conference Room E, Parkiawn Building, 14 Rockviiie, Maryland Wednesday, January 12, i972 15 The meeting was convened at 8:40 o'clock a. m., 16 Dr. William Mayer presiding. 17 18 19 20 21 22 23 24 e - e erat Reportets, Inc. 25 C 0 N T E N T S 2 page 3 Report of the Director 3 4 Information Report on Kidney Disease Program 87 5 Report of the Executive Secretary 124 6 Consideration of Applications: 7 Illinois 242 8 Maryland 172 9 Greater Delaware Valley 223 10 Louisiana 257 11 12 13 14 15 16 17 18 19 20 21 22 23 24 -,*Reportets, Inc. 25 P R 0 C E E D I N G S - - - - - - - -- - - - 2 DR. MAYER: I think we might begin. Did everyone 3 get a copy of the agenda on the way in? 4 The first item on the agenda is the introduction 5 of Mr. Robert Toomey as the new member on the Committee. 6 Mr. Toomey isn't here -yet, and we will introduce him when he 7 comes in. 8 As some of us were discussing at breakfast this 9 morning and last night, our hope is that the agenda by the 10 chan ocess will have provided us a little ges in the review pr 11 degree of freedom in terms of time as we move through things, 12 and it would be my hope that we would have some time to 13 discuss some issues that many of us have had some @houghts 14 about. Whether we will be able to get at some of that this 15 morning or might more appropriately hold on to it until the 16 end, I think we will just use our own judgment as we go 17 along. 18 With that I would like to turn it over to Harold 19 Margulies for the report of the Director. Hal. 20 Can -you all hear back there? We are working without 21 sound. 22 DR. MARGULIES: I will depend upon ray voice carrying 23 far enough, and then if the amplifier comes on I will de- 24 amplify ryself. ce I Repotters, Inc. 25 As you can see from-the agenda, there are a few I general items that-I want to bring for your attention, and 2 1 do know that, as Bill has indicated, you would like to have 3 some further discussion, and I see no reason why N@ve shouldn't 4 get into whatever issues are of concern to you. 5 1 think most of you are familiar with the fact 6 that we are going to have a meeting of the coordinators 7 in St. Louis. This is being set up in such a way that there 8 will not only be a coordinator present from each program 9 unless there is some major conflict in his planning, but tv@.,o 10 other people, which means that there will be in many cases 11 a member of the Regional Advisory Group present as wel . 12 And the conference was set up around the hope that we could 13 develop during the process of our deliberations a @ind of 14 professional discussion rather than one @,liich is dealing, 15 as they so often have, with fiscal issues or with Orocedura 16 issues or with general questions which have to do with 17 federal practices. 18 Now the latter will not be outside of the discussion 19 because we will have present for the meeting Dr. Duval, who 20 will be speaking on Tuesday night, Jerry Reeso, who is the 21 Deputy Administrator for the development part of the Health 22 Services and Mental Health Administration, and we will be 23 discussing some of the swne things at that meeting that we 24 are going to talk about here, including such things as the Repotters, Inc. 25 fiscal outlook for 172 and some of the major program I interests which have been CVOIViDg in RMP and in the Health 2 Services and Motital Health Administration. 3 We have only in the last few days finally received 4 the confirmation of our budget for the current fiscal -year, 5 and we still have not completed our spending plan which has been 6 developed, is under discussion, and should be completed 7 within the next few days, God willing. 8 The totaleppropriation which was passed by Congress 9 has been released for RldP. That means a total of about i45 10 million dollars. Of that total about 135 million is available 11 for what are not considered direct operational costs, and there 12 have been placed on that total 135 million dollars certain 13 specific and designated uses for fund,,--v,,hich I woul(T, like to 14 go through with you for a moment. 15 One of them is and these are fairly final at the 16 present time,. some room for modification, but not much 17 one of them is seven and a half million dollars for area 18 health education centers.' Another is eight million dollars 19 for emergency medical services. A third is 16. 2 million dollars 20 for health maintenance organizations. And the fourth is five 21 million dollars for the construction of a cancer failicty which 22 was an earmarking out of the last appropriation process. This 23 leaves us something in the range of 97 million dollars, 97 to -24 98 million dollars, to which we will add in our planning for I Reportets, Inc. 25 the current fiscal year an estimate, i,.,I-iicii is difficult, 1 extremely difficult-this fir-,,cal -year, of what funds will be 2 available. because they have not been expended during the 3 current fiscal year or during the past fiscal year. In other 4 words, what has been considered carryover money. So we are 5 talking about something in excess of 100 million dollars for 6'the grant process. 7 Now since that represents a very significant 8 increase over the last fiscal year it means that the general 9 environment for spending in the Rl,',P has changed considerably, 10 and it means the fact that we are into mid JanL]C'%ry before we 11 get this confirmation of news raises some serious questions 12 which we will have to talk about during the nexi few minutes. 13 Now let me go back over some of those earni,arl@ings 14 to got an idea of what the issues nre invoJved in spending the 15 funds because they are being managed in a slightly different man)e 16 from what we had expected in the p,-,,,gt. 17 As you remember, the area health education center 18 concept has been a subject of uncertainty for some tire because 19 there was introduced the-administration bill which proposed that 20 the area health education centers be funded out of the Bureau 21 of Education and Manpower Training in the National Institutes 22 of Health, and so in the budgetary process there were funds 28 identified out of the Buroauls budget which are for AllEtC. 24 There were also funds identified out of our bud-et for the same I Repofteis, Inc. 25 purpose. There is now being developer and there should be I Completed Y-iithin the next 48 to 72 hours a process of managing 2 the area health education center out of both resources by a joint 3 revie%,i process. This viiii allow us to have a single place 4 to which applications for area health education centers will 5 go, a method of deciding whether or not they are reasonable for joint funding or better designed for funding under RNIPS 7 or under the-Bureau. There will be a joint kind of site visit a.-id 8 joint review process involved. It is not certain at this time 9 how much of this will be done by contrpp-t and how much by 10 grants, and that question is Still Under discussion. 11 There will also be developed joint q@greci,-,Ont on a 12 set of guidelines describing specifically what is anticipated 13 in an area health education center, and those guidelines are als') 1 4 somewhere near the point of completion at the present title, 15 There have been significant differences between the 16 position of RTTS and of the Bureeu, in which the Veterans 17 Administration has been much closer to the position of RMPS. 18 Over time those differences have gradually disapr,.-ared, so vie 19 appear to be talking in general about the same thing. 20 When that process has been completed and wheh we 21 get an agreement on guidelines and on joint process we can 22 begin to look. specifically at funding for the area health 23 education center. And that process I will got back to in just a 24 moment. I Repofters, Inc. 25 The emergency medical system is also a very recent kini of decision which ha--; V,,rown out of considerations in HF.W and 2 the Office of Management and Budret. There is an .9.ereement A 3 under section 910 RMM can very easily get into the 4 emergency medical service activities. As you know, we have had 5 elements of E?AS in various programs around the country. for 6 some time. In order to manage that in an effective fa%3hion 7 there was created in IIS@.Ti.Aagain in the Development Division 8 which Mr. Reeso manages, a committee to insure that E@ro 9 activities would appropriately involve other prograri@,s in 10 HSII,,HA which are deeply concerned with emergency services. 11 There has been for some time an activity in IISMHA xvhica 12 is confined to emergency services. There is the National 13 Institute of Mental Health which, of course, has sorle major 14 suicide prevention progra-mcj and related kind of crisis 15 intervention,activities. Maternal and Child Health Services 16 is concerned, ainong other things, because of poison control. 17 And this combination and sor;ie otlic,,r activities in 11-31,1111A are 1 8 being combined in the form of a general steering committee in 19 which RitiPS is active along with CHP. 20 The project responsibility for emergency medical 21 services in.this arranger.,,-,nt will be in the Division of 22 professional and Technical Deveiop@.ent in RTIPS, and there will 23 be again a decision made over a period of time regarding 24 how much of the activities initially to develop emergency I Repofteis, Inc. 25 medical systems will be by contract and how rituch by grant. I Now very closely related with this is the mass 2 activity which we have never discussed that I can recall with 3 this committee. That is a program which has been a joint 4 activity of the Department of Defense, the Department of 5 Transportation, and HEW, in which RIIPS staff li@- been-itivoived 6 as the HEW part of it. And it has had a considerable amount 7 of publicity and I believe a considerable amount of effectiveneE!3. 8 It depends in part upon the use of helicopters which 9 are available by the happy circumstance of having military 10 installations near enough to the area being served so that the 11 helicopters are available, in use, are required in any case 12 for training of military personnel, and can be fit in with 13 local requirements. "I 14 Now this has not created a system obviously, and 15 in most cases has been available as an adjunct to an occasional 16 emergency medical system rather than one which is well knit. 17 It is the purpose of the present activities which have IS been under way only for about ten days to foster the 19 development of systematized emergency medical services which 20 cover major urban areas, smaller cities, combinations of cities 21 and rural areas, and some rural areas. 22 There has been set up a process through this 23 committee structure for considering various potentialities, and 24 there will be further action on it and expanding action very I Repotters, Inc. 25 likely in the next fiscal year to help develop stronger emergency medical service systems. These, of course, will 2 include appropriate attention to special problems like those 3 of heart disease, stroke, other medical emergencies, as well 4 as the emergencies which grow out of accidents and other 5 forivs of violence. 6 The Health Maintenance organization activity again 7 takes a slightly different path because it is set up under 8 circumstances which require the HMO development to depend upon lhc 9 use of funds which are currently available rather than on 10 funds which have been appropriated for the specific purpose of 11 HMO. 12 Since we last met or discussed it, or at least in 13 the last few months, there has been established a specific 14 service for Health Maintenance organizations which is 15 parallel to RTIPS and vihich is part of the development group. 16 It will be their responsibility to develop the IP@,Ols, to 17 identify those groups iihich are eligible for funding for 18 feasibility studies, for planning, and for development. 19 And RI&P funds can be utilized for those kinds of purposes. 20 There will be a combination in this activity of grantE 21 and contracts for their development, using some of the contract. 22 money for demonstration purposes in HMO'S. There will also 23 be contract funds available, we believe, for furthering the 24 development of methods for monitoring the quality of medical Repotters, Inc 25 @@ro which will be used as a,p,@rt of the monitoring strength of RMPS and of the RfiPqs as the profframs begin to move from 2 a development into an operational phase. That is the 3 Health Maintenance Organizations. 4 We anticipate that the RtIP's will not be involved, 5 as they have not been, in such questions as the organizational 6 structure of an HMO, the reimbursement systems, actuarial 7 data, marketing, etc., but will'have a major contribution 8 in the professional aspects.of quality, quality monitoring, 9 continuing education, better uses of manpower; and again as we "IO look.at such things as emergency medical services will be 11 in a position to develop special demonstration activities 12 as a part of liMOls to strengthen Elvi@@. 13 The cancer facility which is bein- considered will 14 be reviewed by the next meeting of the Council. We have an 15 application which is in the area designated by Congress for 16 support from the northwest part of the United States in 17 Seattle. There is a site visit which is planned for later this 18 month which will be joined in by a number of programs in IISI*IIIAT 19 by the National Cancer Institute, and by other groups which 20 have been looking at this particular activity; and I think 21 that that review process will probably take place without any gr-- 22 difficulty. 23 Now this leaves us at the point Nyherd we can consider 24 a spending plan for the Refrioiial tledical ProL-,rams and can coli- 4c at Repoitets, Inc. 25 sider such specific iteras as the funds which will go into I believe that I kidney tv-@tiViitiC.9. Vie have proposed, and 2 we will gain acceptance of the idea, that the funding of 3 Regional fledicai Programs in this expanded budgetary 'year 4 will be based upon the relative rating process which 5 the review committee has developed and will allow us to utiliz( 6 the funds in relationship with the capacity of the Regional 7 Medical Program to operate at a higher fiscal level and to 8 utilize the funds for effective pro-ram development. a 9 consequence the ranking process which you have developed 10 and which you have been utilizing will be applied totally 11 throughout this process of inore@-c in funding or of 12 restoration of funding where that has been in issue. 13 There are still some progr@ which are burdened 14 by the fact that their funds were cut during the last isca 15 year e.-, a consequence of very limited funding. b'herever 16 appropriate-- and I think this will apply in many cases -- 17 we anticipate that those funds will be restored. 18 This should allow us for kidney activities a total 19 of something in the range of eight, eight and a half million 20 dollars for kidney proposal funding which would be consistent 21 with the kinds of requests we have and which would be 22 consistent with the needs of other programs, and for general 23 RIIP support. 24 Now this brings iue to one final initial comment or Fellepor ters, Inc. 25 discussion, and that has to do. with the potential need to Set up an additional process or a different time related process for reviewing during this fiscal year. we are now 2 scheduled there Would be a meeting of this revie%v committee in 3 4 April and a w-eting of the Council in May. If we are to offer 5 the opportunity to RMP's to request supplornetitary funds, if v@!e 6 to consider new proposals for some of the now areas which 7 1 have just brought to your attention, it may be necessary 8 for us to either consider another meeting or to set back the 9 meeting of Review Committee and Council by one month so that 10 we can include a larger number of proposals, so that we can 11 give program-s a longer opportunity to develop activities which 12 they m,-,.y have held in abeyance or which they may not have 13 considered because of the discouraging influence of the 14 reduced funding of the last fiscal year. We will have tDhave 15 some further consideration of that during the course of the 16 Review Committee meeting today or tomorrow. 17 We are also considering and this means that we 18 have a number of things to discuss the advisability of 19 using this time when we have additional funding in a relatively 20 short period of time in which to mal,,e wise use of it a 21 change from a four times a year to a three times a year reviciv 22 cycle. Now this is, I must make as plan as possible, at the 23 point of exploratory consideration. It is based upon the 24 thought that from the point of vioNv of the staff of RMPSP Reportets, Inc. 25 particularly the Operational Division, if it can be worried out in a feasible fashion and we haven't gone through all 2 of the dyncAics involved in that "if" there would be real 3 advantages in being able to schedule application submissions, 4 site visits, and reviews with an interval of four months 5 between each of these activities rather than three. 6 At the present time with the reduction in staff in 7 all of the federal programs, including Rl,,TS, and with the 8 clear evidence that our reduced staff requirements are going 9 to continue, the workload on the operations Division is so 10 great that they are spending all of their time and overtime 11 on the process of preparing for review, carrying through 12 revieve, reporting back the results of review, and then beginiil.n[ 13 with the next cycle. This moans that the opportunities for 14 technical advice, for working vqith the regions in other I5 ways outside of this review process, are so limited that they 16 are quite plainly inadequate from our point of view and 17 inadequate from the point of view of the Regional Med ca 18 Progra-iLs. It is a very great problem. 19 On the other hand, if we move from a four times a 20 year, a quadantiual to a triannual program, it would mean that 21 we would have to very carefully adjust the workload on those 22 every four month schedules so that this committee, for example, 23 is not suddenly deluged with a large number of total trisaiiiual 24 reviews at one time, and can have soiie re@-o.-iable balance in F,lb,potters, Inc. 25 the amount of time and att()iition which it needs toglve to the 15 I kinds of pro-ran. reviews before it. And that takes 2 Considerable analysis and planning and e. great cAmount of foot 3 work. If it can be done, however, it provides this kind of 4 advantage for the current fiscal year, and that's why I bring it 5 up in connection with the review cycle. 6 If we were to decide that there is an advantage for 7 staff, for the R@IP's, and for you, in v;aiting oiia. month before 8 we get into the next review cycle it might also be the 9 opportune time if it appears to be worth while to move from 10 the four to the three times a -year cycle because this would be 11 the initial st @ in doing it. It would provide us some kind 12 of funding flexibility because so-me of the fiscal years of 13 Regional Medical Progra@- would have to be changed t'd' 14 accomociate a three has a year cycle rather than a four, and 15 it would allow us to be more flexible in the ways in which 16 we fund them from one fiscal year to the next -- that is our 17 fiscal year -- and would maintain a i,.iore even utilization of 18 RMPS funds in this and in the,tiext'fiscal year. 19 That last Consideration is not an essential one, but 20 in the final management of our-grant avtards it might be 21 an extremely-useful tool. I would not sup,,Frest, however, tlla-t 22 that be the basis for the decision about whether this change 23 in cycle is worth ivhile.. So we really have t@vo considerations 24 in talking about changing the review, cycle. One of them is -Federal Reporters, Inc. 25 only a partial change, which would be to delay the meeting this I year for the rie@.,t review cycle. 'I'he other v.@,ould b<3 to move 2 at that point to a triannual revioNy not triennial, but 3 trianuual. 4 These are sore of the wp.,Jor considerations that I 5 think are worth considering at this particular point, and r 6 would suspect that you may have sense questions to raise about 7 them. 8 DR. MAYER: I only com@meiit, Harold, that as I sat 9 here I was getting warmer and warLqor, and I didn't know whether 10 it was the heat of the room or the 'fact of my anxiety about 11 the magnitude of what you were just saying or of really having 12 a total feel for what -you are saying. 13 Let we go back and -picl@ up vihat I think Y.,iust be a 14 key issue out of what you have said to this group, and that 15 is the issue of the talk about the expansion of the pro-r,-imiiiati,, 16 efforts of RMPS, 'YOU kDOW, striped ayiay from kidney,@;tarea 17 health education centers, et cetera, et cetera, What is the 1 8 magnitude of that component in your best judgment, and v..,hat 19 are your thoughts about commitments towards those dollars on 20 a time span? 21 DR. hIARGui, rr@s l@'f3 considered a Dumber of 22 possibilities, and what seemed to be the @st -- and r have 23 to got affirmation of this -- would be to begin with the base 24 of restoration of funds to all RMP'c,3 where they have been -Fleepotteis, Inc. 25 cut entirely on the basis of budrct reduction because this 1 wfL-3 not .last -year a-progrvmmatic consideration, it Was a 2 fiscal consideration. We would then propose that there be an 3 increase in funding for those programs which the Review 4 Committee has ratedr-ive will call them A, B, C, A being 5 highest rated at the A level, with the decision being made 6 on the basis of the Council approved level, the present funding 7 level of the program, and what apl@ars to be its capacity to 8 utilize increased funds in an effective fashion, In most 9 cases this would be in the range of about 20 percent, more 10 or less, in that range, for A programs. 11 We would also consider those programs which were 12 rated at the B level, but which in general had a relatively 13 strong review and which in time have appeared to bo,ptreiirthe.,n- 14 ing their activities, so that they could be viven 15 sunpleinentary funding this fiscal year -- immediately, that 16 is -- on the basis of the strengths which have been identified 17 and which appear to justify it, 18 Those progr@ vfhich are rated C we would not be 19 able to award simply because we have increased funding 20 because there. is no intention of using this money in any way 21 excepting to maintain prudoiit growth of Regional Medical 22 Programs. If we should get to the point, Bill, where we 23 couldn't use the funds effectively Nvithout giving them to 24 programs which don't rate it we would prefer to return the il'Onc-Y F porters, Inc. 25 the treasury, which is something that no program likes to I think it is going to do. But we would be consistent. 2 DR. @IAYER: We did in 166,. you know. 3 DR. MARGULIES: Yes. It hv,,3 only been done once. 4 DR. MAYER: Let me ask two additional questions. 5 one is how much money are we talking about, and two is who 6 is going to make the decisions and by what process. 7 DR. MARGULIES: We are talking about for the money 8 which is used to maintain the Regional lftedical Prograzis a 9 total grant level of approximately 100 million. 10 The decisions on how much money goes to the 11 program will be carried out the same as they have been and 12 will be. These are administrative decisions. 'I'hey represent 13 essentially the decision of the Secretary, which Picaqs the 14 decision of HSMIA in this pQ-ticulax co-ge, based upon the 15 level,, the relative ranking of the progrei,@ which have been 16 developed through the Review Cor4imittee. 17 DR. MAYF.R: Well, I think in terms of increments. 18 1 need to have the base off of which 100 million compares 19 with. 20 DR. MARGULIES: It compares with last year. 21 DR. MAYER: Which was-- 22 DR. MMGULIES: Approximately 70 million. 23 DR. 14AYER: And you are speaking --let me see if I 24 am clear then. What you are saying is you Are thinking about V'S'poitets, Inc. 25 incrementing commitments towards RITPI,.; of approximately 30 I million dollars then over a time span that presuz-.,4PI)ly is 2 before June 30, 1972p is that correct? 3 DR. MARGULIES: No, what we would propose to do is 4 to first restore funding, add funding to programs-. We can 5 manage to do that and still have available approximately 6 something in the range of nine million dollars, accordin,-, to 7 our best estimates, which then can be identified for other 8 special purposes which we may find desirable, and this gives 9 us a wide range of potentialities. 10 For example, re may find at that particular time 11 and this depends upon our being able to complete the analysis 121 that it would be desirable to expand area health.oducation 13 centers, to develop some major activities for rural,,health 14 care delivery systems, to do more in the emergency medical 15 service system, to develop some contracts to strengthen our 16 quality Monitoring activities. lVe can identify under there 17 circumstances special activities such as a stron-thenin(v L> 18 of our support for the Pacific Basin through the Hawaii ri.@iP, 19 and so on. And there is-also the possibility in 20 those circumstances of some strengthening of l@idney activities 21 if this appears to be appropriate. 22 Vle felt that it would be better not to utilize the' 23 entire sum of money in the first go-round, But part of this 24 decision of what one would do irith those nine million dollars Flde, Reporters, Inc. 25 which are still not committed would dcp(3tid upon whether we I went from a quadrannual to a triannual revieNf cycle, because if 2 we were to do so and we were to to@ advantai,,o of being in 3 two fiscal years at one tii-.e a significant amount of the money 4 could be expended for that purpose. This would lead to a 5 smoother level of funding from this fiscal year to the next. 6 DR. @IAYER: So what you are Saying then is in a.11 7 probability there viiii be an increment of about 21 million 8 dollars into RMP'S, with nine million dollars of that gap 9 between 70 and 100 still hanging in terms of possibility of 10 flowing into those other activities. Is that-- 11 DR. MARGULIES: Right. 12 DR. NLKYER: With decisions to be made adn@inistrative- 13 ly on the basis of, one, those that were administratively 14 reduced, fiscally reduced; secondly, those A prop,,rans and 15 possibly B programs on the basis of rankings of this con..ia-iJ.ttee, 16 and those decisions to be made by when? 17 DR. IVMGULTES: Well, they should have been made 18 already. But we have proposed this spending plan, we should 19 have a decision about whether this proposal is final, and 20 generally speaking I think it i-yiil be affirmed proabiy .this 21 week. 22 DR. MAYER: Okay. Questions? 23 DR. WHITE: Is that nine million dollars sort o an 24 R@ developmental component? Feo,portels, Inc. 25 DR. MARGULIES: Part of it-- Dil. MAYER: Did you a.1.1 hear the question? 2 D,',I. MARGTJLXES: Ile wr,@iited.to l@noNy whether that 3 represents e@n RIAPS devclopmedtal COMPOrICnt. 4 DR. MAYER: That is ten percent. 5 DR. @IARGULIES: It really represents more than anything else the potential utilization of it for changin- fron 6 7 one type of cycle to the next because that could co-sily 8 consume six to seven million dollars of it. Since we 9 anticipate -- of course, me don't know what fiscal 173 will 10 bring us, Nie will see what the Prosident's messa@.re is within 11 the month, but I have no reason to 'believe that it will not 12 be fairly consistent with what we have at the present tire, 13 but likely at a lower level. 14 DR. tlAYER: Leonard. 15 DR. SCIIERLIS: I don't know here the otly-3rs voted, 161 but when I voted for some of the groups it Y;asi) It with the 17 idea that they were able to utilize any more funds than 18 what vie were giving thein. Very often a specific 111,1@'P would be 19 rated A, at least by iwy judgment, on the basis of their 20 having all the qualities that go into a good progrb@A, but 21 still cutting what they had aglced because there was no 22 possibility of them utilizing tho,,ise funds in a manner which 23 would justify their bbing granted. 24 In other words, vihi.l.e you stz?,ted'that some of the Repofters,inc. 25 reasons were purely fiscal, I qtiestion in niy own riiiid how I y.o@u could utilize 'the large illeroDient that you have stated 2 in a manner vtlxich N7ould justify their b@-ing util ized 3 merely because these were rated P-9 A's. And also you state(] 4 this would be purely an administrative decision, is that 5 correct? 6 DR. IIOGULIES: (Nods.) 7 DR. SCHERLIS: I have so-,no questions as far as being 8 able to really spend these funds in a v.,&;y which would justify 9 that large increment being used. 10 I have several other questions. Can you answer 11 that one? 12 D.q. )@ARGULIES: Yes, I thinlc the answer to your 13 first question is relatively simple. The level of- undidg 14 which,you have approved for progra,@ and which vias approved 15 b-y the Council is al%,iays way above v4hat thoy are actually 16 'given in a grant award. There is, generally speaking, 17 for A programs -- and there are variations in this -- a level 18 of grant aviard which is not higher than 65 l@rcent of what 19 Council and you have approved. So you have approved for there 20 levels well above what they are now receiving. There is littl( 21 reason to doubt that they could utilize the funds which you 22 have &greed they could use. 23 DR. SCIIERLIS: In other words, as far as the Review 24 Cominittee recoinibendations are concerned your feeling is Fe Repoftefs, Inc. 25 that when we ask for a ful@ funding only 65 percent on'the average he,,@s been given after the final. rr,-@ntinf.- ineclianif3r.',, 2 is that right? 3 DR. MARGULIES: Th,%tts right. There are variations 4 of that, and that is simply because we haven't had the fund.-, 5 to do it. 6 DR. SCIEERLIS: Of the tote.1, Yhich was 70 million, about how much of that is going in next Linder direct or 7 8 indirect support of develop@,riont of IU,10's? You hLtvo earrisarl@ed 9 10 DR. IIPRGULIES: The Tr@io is separate from this. 11 DR. SCIEERLIS: Is it rc&>.Il-y? I aln tailzing about how 12 in some of the regions a grert deal of C).eve.Lopr4@eiital work is 13 toy@@d lt'40's. What percentage of that, not the earmarked 14 funds. 15 DR. IIfiP,,GULIES: I don't l@jic),v@ the atisvror to that, 16 But the amount of money @-hich the Rl,,Tls are none currently in- 17 vesting in Iftfols is not verv great. But vie don't have a 18 figure on it at this point. It is not 8. large surq at this 19 time. 20 DR. SCIIERLIS: What sort of rovic@v Mechanism are 21 you thinking of for AIMC and ET,1,3, and so on? liotild that be 22 part of the total revievi niachanis,.P. in a region c>r would 23 they be separate review riechanisirs? 24 DR. 14ARGLTIIES: I'le h-.-k-ven't Eottled that issue 'yet. Fe C-potters, Inc. 25 My oivn preference on this on(i is for us to go ti-irough the I revie@7 process for area 1-i--alth edLICc.-Ition centers in a manner 2 similar to what we would do for regular RI.,IP review, and we 3 have gotten close enough to the completion of guidelines 4 so that I think we will be able to bring them to the national 5 coordinators' conference next week in a final form, or at least 6 give them to them within a few days after that meeting. But 7 whether we will bs free to go through the regular grant 8 process in this limited period of time or not is a question 9 that hasn't been settled, and it has to be settled at the 10 level of the administrator of HSIBIA. 11 MR. PAPKS: I would like to get some information as 12 to the actual volume of funds. As I understand it, 13 approximately one-half of the fiscal year has expiro'U at this 14 point. And you are talking in terms of roughly the 30 million 15 dollar increment that would be allocated and applied to 16 the various programs. Isn't this in fact by virtue of the 17 shrunken year a double impact for progrt.@atic Absorption 18 By that I mean 30 million with half a year expired would 19 have the impact of roughly 60 million if you are talking about 20 utilizing it between now and expiration of the fiscal year. 21 Or do you anticipate in this that there Would @ rather ip 22 substantial carryover balances that ivould go to extend 23 programs? That is one questio 6. 24 The next question is this: that shouldn't there be Fe potters, Inc. 25 some review identification of the total problems that you I have within Rfi',Plsp and I &,n tal.Ring no%;,, about tlio programs 2 throughout the country, and shouldn't this money be earmarl-,cd 3 so that there is some specific onus or burden, if you will, 4 upon these programs to achieve those thir,-s that you are 5 trying to got done either nationally or those things which 6 regionally -you feel to be desirable? 7 DR. tIARGULIES: Let ri,.e answer the first question, 8 which is loss complex than it would appear. I am glad you 9 asked it. What we did after the last review cycle for those 10 programs which -- you see, our fiscal year is not the same 11 as their fiscal year, Nyhich is a saving factor in this. 12 The review cycle which was completed in August virs for 13 progress which had a fiscal year, their own fiscal year 14 beginning in the fall, in September and in October. At that 15 tilde we decided to run the risk, or rathdr I decided to 16 run the risk of anticipating a higher level of funding, "@nd 17 so those programs have v.-Ireedy been given a significant 18 increase in their funding to begin their fiscal year. So that 19 they have started at a higher level, at a level i@,,hich is 20 fairly consistent with v@ehat I on, now proposing, That is the 21 A programs and to sor-M extent the B promises. 22 Now the last review c3rcle which you completed when 23 you were here last time is for program!i for the fiscal year 241 which 'began January 1, so that they have a full ficcal year Fcdefal Repoitets, Inc. 25 coming up, and if we supplement the grant award,, which were initially made before we got the release of funds for them 2 they will have lost no more than orle iniozith out of the fic,@cal yenr 3 by the tire they get to there. 4 The remaining funding which is in this review 5 cycle and in the next one is for fiscal expenditures which 6 have yet to be started in their fiscal year. So that in fact 7 we will be dealing viith new fiscal -years for the Regional 8 Y.Odicai programs, and it isn't as though they viere all half 9 way through their year. 10 We have accomodated for it in the first group, and 11 the other three-fourths of the programs have just started 12 or have yet to begin their fiscal years. 13 DR. MAIT@R: Does that ansNyor that particular 14 question, Mr. Parks? 15 14R. PARKS: We.L.Lt I assume then administratively 16 -you can handle the allocation of these funds. 17 DR. MAIIGULIES: I think we can. 18 DR. MA'i'ER: Without a significant build up in 19 carryover obligation, I thi nk that is the que stion. 20 DR. MARGULIES: I think we can, and, of course, that 21 has always been a problem when you got this late in the 22 fiscal year. It is distressing because in fact the 23 appropriation process was completed in August and there is a 24 determination in Congress rirliti)ow to get this yoar's -Federal Reporters, Inc. 25 appropriation process fijiislio(j before Jul-,v. If we had this' I kind of allocation early in our fiscal year it would obviously 2 be much easier. 3 And the answer to your other question is 'yes,,there 4 is a desire to emphasize some of the major movements which 5 HEW and the administration have been supporting in the health 6, field, and one of the reasons for designing the coordinators 7 conference ar ound the issues that we have, access to medical 8 care, emergency medical services, area health education 9 centers, improved forms of health delivery, is to emphasize 10 movement in that direction. That is also why I think such 11 things as emergency medical services and area health education 12 centers have been identified as special kinds of activities 13 for increased emphasis. 14 DR. tiAYER: Jerry. 15 DR. BESSON: I have a somewhat complex question. 16 176 have anow stated mission for RIIPS articulated in the I)a--,t 17 year, and as a review., committee v@e have been asked to IS emphasize in our assessment of individual regions the conpj-iancu- 19 of progranA regionally with new mission. As I will come to 20 when I discuss the regions which I have been assigned, tile 21 staff opinion and the director's opinion aboutthe 22 appropriateness of a particular pro,,ram has to be in light of 23 new mission of RMPS. But yet I"- I add up these f igures I 24 find that we have some 37 million dollars allocated to area Fed Repoltels, Inc. 25 health education centers, 111@10's, and emer[!,ency medical I services, alld construction of c,@ncer f@ility, all of which 2 is consistent with neN-i program. Implicit in this then is tint 3 the 100 million dollars should be allocated to the old 4 program, if you will, and yet we fault individual regions for 5 not being @n line with new RMPS directions. Speciaily-when 6 I'come to my region I will note that staff has allocated 7 only maybe 20 percent of the requested amount because the 8 program was not in line with new mission. 9 I am,not sure that I really understand how this 10 review committee should function, whether we should view 11 the entire 140 million as being available only for new 12 mission, whether vie should view that money as having to- be 13 spent because if it is not spent it may not be agaiR allocated 14 next year no matter r-ihat the progrqm is, vihother @,e should 15 be selective in viewing an area as being A, B, or C 16 depending upon how adequately it is in line with new directions. 17 And I think we really a- a review committee have to have 18 a little bit more clearly articulated inodus operandi in 19 light of your statements-this morning, and perhaps you can do 20 that for us generally, although most of us have done our 21 homework before we came here. 22 DR. ft4RGULIES: Well, now that is not a complex 23 question. You can do better. TI-iore is no question but 24 that there is no implication in the 100 million dollars which FeloPortefs, Inc. 1 25 is not earmarked for anything other than the new directions I which are part of the mission statement. One year ago today th) 2 now obiigational authority which had been recommended for R@IP 3 was 52.5 million dollars. We are now operating at the level 4 which I have just described. The reason for the change 5 in the level of support of Regional lledical Progr@ is 6 essentially because it has designed a new direction which has 7 support in Congress and in the administration, and if we 8 should utilize these funds for anything other than to 9 strengthen these now directions I think we would be doing a 10 disservice to the intentions of those who have appropriated 11 the funds. 12 There is no suggestion so far as I am concerned that 1 3 we should utilize these funds raerely to be utilizinrtthem, As 14 I indicated earlier, if there is not an effective way to 15 use them in a manner consistent with the mission statc@ment 16 and rtith the total directions in which we would like to see 17 the RIIP's go then we certainly shouldn't sps--nd the funds. 18 In other words, I think that it would be inappropriate 19 for this review committee within the limits of what people 20 can humanly do to review these Regional Medical Progreitlis now 21 on any other. basis than v@hat they lic?.ve done i.n the pq,.Et. 22 We have asked you, and 'you have, I think, reviewed tlieni not 23 on the basis of what kind of m oney might be available, but 24 rather on what they are merited in term of support. ive F'oepoitcls, Inc. 25 have tried to keep separate liinitod funding from the quality I of the program. We should also iceop separate more generous 2 funding from the quality of the progreju. It should be review 3 on the basis of the r,@,orits of the R@IP and the way in which it 4 is consistent with the review process, with the mission 5 statement and the directions in which RI@ZP's are none going. 6 DR. BESSON: Again the legislation says so.,.wthing a 7 little different than that statenont of a year ago, and I am no- 8 sure how this 140 million dolit@rs jives with these two 9 statements which seem to be som-y-@,hat inconsistent. The 10 legislation asks for support of programs that are in line 11 with improvement in the care of heart dist3a,,se, cancer and 12 stroke first,, and also not as an afterthouf,-ht necessarily, 13 but maybe as a political staternetit, include somethitiF %thich 14 has been expanded to be the new mission. 15 1 an, still not sure then is I review a program 16 whether any pro-rams thrtt are not in line with the objectives tiat 17 were articulated a year @,,o, whether those progr@,, should 18 be funded. 19 Now eight months ago this came to a head in t s 20 corznittee when as a matter of testint,, the waters I was 21 reviewing the Iowa program -- excuse Pie, Miss Kerr, but we the Iowa 22 will got this out in the open I was reviewing 23 program and asked that the Iowa pro@,,,riAn be denied completely 24 because it was inconsistent Nvith tile i@iew mission of R@,q) over) thou F poiters, Inc. 25 each of the new programs were mcri.4t,-orious. Tho Review Coruniti@:)e I upheld that position and passed it up to Council. Couiici.1 2 reversed the Revic@y Committee decision, and the message that 3 1 got from Council &t tha t time that this was an 4 inappropriate action of the Review Coinmittee. flaybe in the 5 intervening eight months the entire emphasis of ni@,'PS h@- 6 changed. Vlore thet actio n to be taken today I would be 7 very curious as to how Council would react. And I am not 8 sure that I clearly understand how I should review a profrram 9 in light of this statogient. 10 M. MAYER: Let me just emphasize that one, Harold, 11 because I just blew ail of last Sunday going through that 12 exercise myself in another frD-vne of reference, Jerry, in 13 terms of legislation,and v,,hat I assuiii,3 'you a-re calling our -14 RIIPS mission stateriont was that rather lengthy -letter that 15 tends to confuse frankly mission, goals, objectives back 16 and'forth, and it is hard to get a fix on what it is that 17 is really being specifically stated, and then take a 18 look at other information that has been provided by RMPS 19 various devices and-it does get a little fuzzy in terj,.i-a 20 of what really is being said. And the thing that got to me 21 was the very point you are Wnking. 22 In an attempt to try to get some clarification of 23 this I went back to the new and c:b.11 that did was serve 24 to confuse me even further in term.- of where we are. And Fi§epot tefs, Inc. 25 I think we really do need soine clarification here oti.tlii.,3 I one and what are you intents alio about a i-qore e7cpiicit 2 statement than the one that has already been produced. 3 DR. liARGULliT,S Well, I suppose the best thing @l 4 can do on this is to paraphrase what the Secretary said and 5 which I think is a valid stateDIODt, and that is that you can 6 read the RMP legislation and make out of it anything you want. 7 When I went before the Appropriation Co,-n.,iii.ttee last 8 year I described the kinds of directions for RP;W which we have @9 been supporting here, and these were acceptable to the extent 10 of the kind of support which you have witnessed. I don't think that we are at the present time trying to be non- 12 categorical, but we are trying to eschew the narrowly 13 categorical, the kind of thing that picl,,s out one pf-rt of one 14 phase of one disease and concentrates on it because that 15 appears to be a nice thing to do. 16 I don't believe that I can settle for you the line 17 of distinction between an effective program which is 18 concentrating on one aspect of the system and an effective 19, program which is taking a broader base. I think there are 20 raaiges of distinction, and I am not convinced, although 1 21 would like to hoar more from other members of the Review 22 Committee, that this is as difficult a distinction to make as 23 it appears to be. Unless -you,aro talking about whether 24 it should be a program as it was three years ago rather than -.4toPoiters, Inc. 25 as it is at the present time, because there has boon a I significant change in v,,Iiat the P,,,Il"ls arc doing; tlicre is a 2 movement in the Regional Medical Prograins toward the creation 3 of a more effective kind of gocil, and I think the review 4 process has identified that. But there has not been produced 5 in this process of review evidence that each RIAP is like every 6 other Rl,',.P, and I think that those kind of differences can 7 continue. 8 So far as the Iowa program is concerned, Jerry, that 9 was not overruled on the basis of your interpretation. That 10 was a difference in your interpretation. They did not agree 11 with your analysis of the program, which is fair game. 12 DR. BESSON: Say that again. 13 DR. I.MRGULIES: The change from the Revic,@v Committee 14 to Council vias a change in perception of what the program 15 represented. 16 DR. BESSON: 'I thought our decision here represented 17 a statement of principle, nairoly thatt at least as I plirased 18 that resolution, we Here testing the Councills intent to 19 fund only programs that.-Yiere in line viith now.mission. Seems 20 to i-de that that particular pro-ra.,,i, the kinds of things that 21 they viere asking for viere still an the old model, and that 22 t-his might have been a good test. But maybe we chose the 23 wrong test. 24 DR. ISARGUI,IES: That was just 0. matter of professions repo(ters, Inc. 25 disagreement. DT. lfif,,Yl'll: Dr. Bxindley. 2 DR. BRII.'DLEY: I would to ask a question and 0 3 make a comment if I might. I have a. di-oiagree),,iotit with Jerry 4 about the point he was just mentioning. I really question 5 -the -- I would like for us to say that we would review each 6 region having been proposed to us, what their needs were, how 7 they could best iiiaet those needs and how they would utilize 8 money to improve health cttre. The question v@ouid be who 9 determines what national goals, objectives and priorities 10 are. If the regions, like Jerry mentioned, all have to 11 conform to national goals and priorities what input do they 12 have to comment on \,.,hat they need and how it will apply to 13 the'm? We don't seem to determine it. Does the Counci 14 determine it? Who does determine that? 15 DR. 14PtRGULIES: National goals and priorities 16 are always the prerogative of the administration. That is 17 true year in and year out. The legislation for this, like 18 every other program, says that the National Advisory Coubcii .19 will review prograr,,s and it will rialro recommendations to 20 the Secretary. The decision about graDt aivards -- the 2 1 decisions are made by the Secretary. That is always an 22 administrative decision. And consequently so also is the 23 definition from one period of tine to another of what 24 represents the major goals and objectives of the government -0 Repotters, ltic. 25 in.the development of budgets and in c--)Nrponditure of funds of its progrLxis, and that is a part of tho general political 2 process. Now whether that is right or xrong is something 3 that I don't believe I aiii competent to judge. 4 DR. BRINDLI,;Y: Lot me you one question concerning 5 the H'90's and area health education centers and things of 6 that nature. That might be the very best way to use our 7 money in some areas, it might be in sorie areas that is not 8 the most effective way of delivering health care. Now 9 according to Jerry, we would be critical of that area that 10 doesn't wish to go about it in that v@ay because for-therd 11 another method is better. 12 DR. MARGULIES: No, I think that is a perfectly clear 13 point. Let's be specific @,bout so@ietliing Into tlio',Ileaith 14 Maintenance Organization which is somethinvtliat the 15 administration is keenly interested in. There is no constra n 16 elf deeply involved upon a Pegional Medical Program to got its 17 with lil!Ols. If they say that they think we caLi serve the 18 broad purposes of our region and be consistent with national 19 goals by'restricting our activities to a certain phase of 20 the health delivery system -- a good example that we revic@7ed 21 last ti,@ is the Ohio Valley RMP which you are familiar with. 22 Their concern has always been concerned with the improvement 23 of ambulatory medical care and with via emphw-gis on better 24 -F&ROportets, Inc. uses of health manpower, and they have not covered a lot .of 25 other activities, that they say for our part of the country I that is the best thin[.,. If you masure that against the 2 broad statements which the administration has been emphasizing 3 of increased access to care, of improved product of the 4 system, greater efficiencies, cost containment, etc., 5 there is no inconsistency. 6 On the other hand, if the purposes of an P.@IP were 7 to provide 'transplant facilities in as many hospitals as 8 possible over a short @riod of time, to pick an absurdity, 9 1 think this would be unacceptable. 10 Now it is the range in between which causes great 11 difficulty, and it is why we have a review committee upon 12 whom I don't think v,,e can impose a very strict kind of set of 13 rules, but one which is broad enough to allow you to use -your 14 judgment. 15 DR. BRIIIDLEY: If Ohio Valley says they can do 16 the best job in this manner that is all right? 17 DR. MARGULIES: That is the main purpose of the 18 program. 19 DR. MAYER: Mr. Ifilton. 20 tM. HILTON: I just wanted to say prior to what 21 has just been .uaid the suggestion perhaps that there needs 22 to be better communication betvieen the Executive Branch that 23 articulates national goals and the local regions. Part 24 of the reason that my recent site visit was agonizing wm -I*Repottets, Inc. 25 because we ran into the situation the Jerry and others have identified vvhere people vroro in effcct quite frustrated, 2 wanting to know from us what it is that they should do so 3 we could evaluate them so they could get money. We talked 4 as best we could about program management and kinds of 5 things to keep in mind, but I think %,ie all had a flashing 6 around there of the real issue, and that is we cannot perhaps 7 effectively evaluate unless it is quite clear to usi.what it is 8 that needs to be evaluated-, and give ratings and vihat have 9 you. And the issue of money always gets in the way. People 10 always want to do whatever it is they are going to get money 11 for. 12 So I think that needs to be made clear in our 13 minds as we look at the program, precisely what it-@s we are 14 evaluating for, and I just echo his point. 15 DR. ItkRGULIES: Well, I think that is a very 16 valid criticism. I think we have beon inadequate n our 17 capacity to get to the regions and to do more than simply 18 send them pieces of paper. We need to have a better capacity 19 to work-directly with the regions; and at the present time 20 with the staff strength we have and with the demands that I 21 have described in the revieii cycle this is being done very 22 inadequately, and I see little kind of relief from it unless 23 we are able to lessen the de)nands of the review cycle, which 24 is one of the reasons for going on a three tiDie a year basis. @l Repotteis, Inc. 25 people in The people in the operations Division, 1. the I)rofessional and Technical Division, are so heavily involved 2 with the activities which arc now., consuming their tire that 3 that aspect of it which is -- really the 4,o,,y to communicate 4 is to be with people a.-id talk with them and to examine what 5 they wish or what they think needs to be cone against what 6 their understanding is of r.,hat should be done, is essential. 7 And yet we do have a real limitation on how iruch we can do 8 about that. 9 hM. IIILTON: On%-le that kin(] of coir-@unication and 10 dialogue is under way then will staff be conununicating these 11 local needs and concerns to the appropriate people? 12 DR. UMGULIES: That is our intent, and, of course, 13 that is one of the reasons that we ivorlied so hard, and we altqost 14 were unable to do it, to get Dr. Duval and to get Reeso to 15 the national coordinators ny--eting, because this will give 16 them the first opportunity to not only lay out for that group 17 what it is they expect of Regional lledicai Programs, but also 18 to zuiswer the kinds of questions which the Review Cownittee 19 is raising. 20 But there is a long chain of events from Pennsylvania.. 21 Avenue to Independence Avenue to the Parklawn Building to 22 the regional offices to the RMP'S, and in the absence of close 23 working relationship it is extremely difficult. I am not 24 satisfied with it. I one' id that would be most dish .t if I sa Fie epottefs, Inc. 25 1 was I DR, NLf,.YER: Ilarold, 0110 Of the questions Nvhich I 2 asked which got lost %Yhicii I would like to reiterate is is 3 there going to be an attempt to develop a more explicit 4 statement and perhaps a more organized statement than the one 5 that has been developed as of now relative to RIIPS mission, 6 -goals,, objectives? 7 DR. @IARGULIES: Yes. I must tell you that the 8 production of the one that -you are talking about was in itself 9 an extremely complicated task, Interestingly enough, even 10 that one, when we have met with coordinators and staff, has 11 been looked at by very few people. We had a meeting of 12 several coordinators in here not long a-o and 65 percent of 13 them had not even looked at that mission statement.,, 0 -you 1 4 kno'w,, we can do it and we will do it, but it is going to 15 require a great deal more'than that. 1 6 DR. MAYER: It is very, very important for us that 17 have read it five times and still don't have a clear picture. 18 I think, you know, you gear your educational program to the I 9 bright on-es in the class as well as those that are moving 20 along slowa.y. 21 DR. MAIIGULIES: Well, I can say this about it. I 22 like the way it was written in the original form. 23 DR. MAYER: All I was commenting v4,as that there are 24 some of us who didn't, and we would appreciate some-- Reporte;s, Inc. 25 DR. MARGULIES: No, I don't mean that forui; I mean I the original form. 2 DR. MAYER: Jerry. 3 DR. BESSON: Well, I think that is critical for the .4 entire program, and the whole way in which the Review Conunittee 5 operates has been very elusive. The Jay the Council reaches 6 its decisions -- I have used the term capricious before, and 7 I will use it again, because we seem to be operating under 8 directive guidelines. Now that is because the administrative 9 staff of RMPS under the Director is sonioNihat chary about 10 ordaining how RIW should be run and would like to remand to 11 the periphery making decisions, and, of course, the anniversary 12 review process implied that this is the way it should be 13 done. But in so doing the periphery and the Review;Coir-mittoo 14 are left in a double bind. 15 On the one hand vie are told that the center will not 16 ordain how the periphery will run its affairs, and the 17 periphery will organize itself to do its own program prior ty 18 determination and we will either-say yea or nay depending on 19 whether they did it right or not. But on the other hand, 20 as I review programs now I see that staff does ordain 21 because they say these particular projects don't seem to be 22 in line with now mission, therefore we will cut funding from 23 X to X minus 100 K, or whatever, That leaves the region 24 in a double bind, aiio they grasp the straws that emanate from @l*Repofters, Inc. 25 this center when they see the mission statement, and I see I it quotcd very Nviciet-y, @ct".use there, is very little guidance 2 they have from the center. 3 The Review ConLnittee I think is left in the se@ii-ic 4 position. Even after having served on this Review Conunittee nov 5 for close to three years I am not sure that I understand what 6 I am doing and how I am supposed to bci doin- it; and in that 7 candid statement I think I i-,iust say that others on the 8 Review Committee and Council,, let alone the coordinators, 9 must feel in the sane position of trying to group atelouds 10 and not quite sure vihether what they are doing is appropriate. 11 So I again make a plea for some frequont-articui&tio them what 12 of what it is that vie should be up to, or telling 13 we are goingto do and how to go about it within broad 14 guidelines and let the area choose its own tnodus operandi 15 within those broad guidelines. But these guidelines are 16 necessary again and again. 17 MISS KERP,: I thinIL what N-.e are generally saying, 18 we are floundering -iomewhere, and Jerry JuF.,t said let alone 19 the coordinators -- and while my information came to me 20 very infernally, I think it is the appropriate time to'bring it 21 out, I think the coordinators are floundering. Some visits 22 I have made and have heard others have made, there were 23 comments llvihon you Fods malre up your mind," actually free 24 the group as we visit them. So they, too, are feeling Repottets, Inc. 25 aiaxious about this. I!y understanding is that the coordinators have 2 emplo-%,ed an attorney. The source of the funds I don't knots,. 3 One wonders. But for what reason, I %4ould ask the question. 4 Is their level of anxiety so high that they feel they need 5 legal advice, or is my information incorrect? 6 DR. IIPIZGULIES: The only one that I am acquainted 7 with is the-foliouv who serves &"- a secretary to the Southeast 8 area coordinator group. Presuinably the fact that he is an 9 attorney is incidental to his general orgDDizing and 10 secretarial responsibilities. I have the impression, however, 11 that he extends his efforts in many other directions, and 12 I am not very keen about it. But it is being paid for, 13 1 believe, by a combination of Regional Medical Prograi-As. 14 What he does is help convene inetings and help develop corunon 15 programmatic concepts among the Regional Medical Programs in 16 the Southeast area, 17 DR. MAYER: Leonard. 18 DR. SCHE@RLIS: I would suggest that they could better 19 put these funds into getting a psychiatrist. 20 (Laughter.) 21 1 didn't want Dr. Besson's comments to go further 22 unconunented upon because I share a great- many of his doubts 23 and anxieties. I confess I always feel better after the 24 morning session than I do after the end of the second da,,y at et Repoftefs, liic. it 25 those Review Committees because I am reminded of Of Mice and I Men," there are two characters, Ceortre end Lennie, and 2 since my first name is If@nard I have some feeling for it. 3 Lonnie is rather simple-minded. In fact, he has some cerebral 4 impairment. 5 DR. MARGULIES: Bigger than -you, though. 6 DR. SCI-EERLIS: Much bigger than I. But for assuranc 7 he always asked Gorege to tell him about the rabbits end then 8 he feels better; and it is always nice to have Hal tell us 9 about how the reviciv mechanism might work. 10 I do have a great deal of concern because frankly 11 when I go'to some of the regions for site visits -- we are 12 there very much on a very important basis obviously, their 13 longevity and their very existence can depend on our 14 decision, and I find it very difficult to really be in a 15 position, except very often have a good guts reaction to 16 what goes on, I have a feeliDr abdominally that is good 17 or bad, and then I translate this, as I will today, into 18 specific funding reconunendations it) terms of dollar value,, 19 and I can put a color value on it, it is pink or blue, but 20 it is hard to really put a dollar value on it, 21 1 am getting increasingly impressed with the 22 similarity of goals and objectives in the regions, and I 23 could be naive and Resume that they all openly define the 24 ultimate truth simultaneously v.,Iiich doesn't really seem to be. eporters, inc. 25 realistic, Or else the realistic thing is that they know wh,@t I the goals and objectives are, because if I put out my hand 2 frequently enough pith the Nvrong bott le I am sure I will get 3 it slapped,eventually I will know that other bottle is the 4 right one. I am sure they get the message. The rewards 5 are obvious enough. And I think that what we discern as 6 the regions are beginning to really decide what their real need@ 7 and objectives are, the question whether it isn't reaily a 8 cyclic mechanism, if they know that if they define the goals 9 and objectives a certain way the funds will not be forthcoming. 10 And I[ am impressed when we talk about some regions having 11 turned the corner that it is iverely that the smoke signals 12 have become denser and denser from the spot from where they 13 emanate. t 14 I do have concern now that @ve again are talking about 15 defining goals and objectives and Do,.v that we are add ng 16 what are reaily tremendous challenges -- ABEC'S, a- I view 17 them,, are tremendous challenges to regions, and the potentials 18 of duplication, of confusion, of overutilization and few 19 resource people, the attempts to define needs on the basis 20 of groups as set up in that document are horrendous. It was 21 a document which I went to @d last night and I awakened not 22 any clearer in my own mind, though very often sleep does 23 have benefit. I am increasingly confused about the goals and 24 missions of R!IP, particularly how they get translated into C-poftels, life. 25 the field, how we can sit here and decide how these funds I can best be expanded. 2 I hope that o,,3 the morning goes on we will have 3 further discussion because I think that as -you determine 4 the dilemma many of us face it isn't quite as clear when we 5 are out there in the f ield working and trying to reach an 6 important decision how we can put into clear focus some 7 of the priorities that are obviously required. 81 DR. MITYER: Let me raisb two quick points, Harold, 9 and it relates to AHEC's because I think that gives us an 10 example of two issues. You talk about a combined effort with 11 the Bure8u. You commented that 7.5 million would be set 12 aside, and possibly more if there is some left over of the 13 nine for that activity. How much is the Bureau putping in? 14 DR. M.AY,.GULIES: At the present time approximately 15 il million. 16 DR. NTAYER: Then the second question which [sets bacl@, 17 to Dr. Brindicy's point in terms of who sets national goals 18 and priorities, I think it would be helpful to us if we had 19 some feeiing of how your document of Decerrber 23rd on the 20 relationship of area health education centers, how the 21 RMPS position paper was evolved and who developed it, 22 because'I think that does in fact have an impact on policy 23 very clearly as people think qbout that kind of effort. 24 DR. MARGULIES: The area health education center Repoi tets, Inc. 25 document which will emrge, and as I indicated earlier in I the morning, is just being corqpiet(,,(] as a rot of guidelines 2 is being developed cortirtioniy -- and.by that I inoan by staff 3 work within review and approval by those under v/hom they 4 operate, with the Veterans Administration, the Bureau of 5 Education and 74anpower Training, the Regional Medical 6 Progran, Service. And the process that will be followed so 7 far as liE@W is concerned is to create a set of guidelines 8 which are accepted both in the National Institutes of Health 9 and the Ilealth Services and Mental. Health Adrpinistration; 10 this when it is in a form which is acceptable to Dr. Wilson 11 and Dr. Marston v.,ill be signed by them, sent to the 12 Assistant Secretary, to I,-ionty Duval, and if it is acceptable 13 in that form will then be used P-,q the guidelines for the 14 development of area health education centers governing the 15 activities-of both Bureau and R?,IPS. 16 We will continue to operate together under those 17 guidelines in the process of review and support of.area health 18 education centers as the proposals come in and as they go 19 through a joint review process. 20 DR. MAYER: Lot me just pursue this one step further. 21 You indicated that in that joint review process there would 22 be the possibility that it may be funded totally by NIH, 23 totally by IISIVAA, or combinations thereto, mthich sort of 24 implied to ins that there'were different kind of Iabots to F epofters, Inc. 25 justify the reason for that. And if we are talkidg about Joint I guidelines then I don't understand v,,Iiy there irn't a joint 2 pool of money. 3 DR. IMPGULIES: Siz,,ipiy because the funds have been 4 appropriated by different processes for different organizations, 5 and the b,-,st that we can do with them is to work out 6 arrangements in which there is a reason for both of us to be 7 involved in the funding of one activity. 8 But you are quite right in suspecting that there is 9 still some difference in perception in the Bureau and in R@IPS, 10 and I don't think those differences have been completely 11 resolved, and I agree that that is an unsatisfectory-state of 12 affairs. That could be resolved in the office of the 13 Secretary, and up to the present time has not been.. 14 MR. PAR@ I raised some questions about certain 15 things of national emphasis and how the money was going to 16 be used and this kind of thing. I am going to raise it -a 17 little more specifically for two reasons. One, .I think it 18 was oversimplified when it was originally put out. And 19 secondly, it would require me, I think, to compromise a bit 20 with intellectual honesty. 21 For example, I am concerned about the overalici.vil 22 rights compliance, the whole process of RMP'S, their existence, 23 their operation, and the Mechanisms by which they carry out 24 whatever it is that they are doing. Do we really know about eporters, Inc. 25 it? In terms of our evaluation shoot, ,vhicii is fairly I specific, we have minority interests here which is rated 7, 2 I guess, in terms of weight. Yet in torins of the status, the 3 -articulation of the law -- this is a law and order matter 4 by both the Executive Branch, the President, and your 5 Secretary, there are certain specific things that I have 6- question about whether there is in fact compliance with the, 7 law. 8 The question I put to you is whether additional 9 money should be put into a process that further extends this 10 kind of aberration is a fact that needs to be addressed I I herehonestiy and openly. 12 1 am not sure, for exaziple, from my review of these 13 pa@-rs end from the one site visit that I have beerx on, which 14 not terribly helpful, that there is an equal craployr-iont 15 opportunity, that there is an opportunity for equal 16 participation of the black professionals, that there is an 17 equal opportunity for access to the granting process, that 18 is to participate as applications for grants or for programs 19 from the Regional Medical Progrwns themselves. I am not 20 sure whet it is in terms of so-called staff administration, 21 what instruction do they have. Are the instructions Of 22 tho Secretary of IIE-IV in fact being carried out? 23 And let me give 'you an exeuiiple. I have here a letter 24 from the Secretary, and it is a letter addressed to me, and Repofters, Inc. 25 this will give -you the kind of'exalliple that really creates a I tremendous problem. And we Pro ta:lkirir, about money. @'Ar) iie y 2 is it. Health, everything else revolves around money. Thi's@ 3 is a money system. We are tailiing note, about the 4 dispensation, if you will, of 100 million dollars cash or 5 in favors, whatever it might be, 6 This is a letter dated August 9, 197i. It is 7- addressed to me. It is from Elliot Richardson. it says: 8 "Dear S ir: 9 "It has been the policy of the federal government 10 to encourage and promote the development of minority owne 11 enterprises.In conjunction with this policy the government 12 has intensified its efforts to incre@-o the deposit 13 of funds in minority banks. Those institutions ar(3 themselves 14 small minority enterprises with most of their coimnercial 15 accounts being other minority business heqAs. Vle should like 16 to encourage your organization to deposit a portion of the 17 funds received from this department and other sources into 18 minority banks located in your vicinity. Stintu.LatioD of minor t: 19 banking communities will enable these banks" 20 He goes into this, he, has attached to it a list 21 of the banks. Has this in fact been dispensed to the 22 RIAP'S? Is it a part of the process that you go through in 23 reviewing these R?flpls? 24 0 1 take this as a specific kind of example. I just @@-Fedeial Repoitc-ts, Inc. 25 happen to have this in connection with sonothi@ng else, There are a nu),ib,-,-r of otlior l@inds of directivc)s thnt 2 have come down that pert,,-,.in directly to the dispensation Of 3 federal funds, and I am not so sure here with the guidelines 4 what role these things should play, Nyhether we should continue 5 to participate in the further extension of these kinds of 6 law and order aberrations -- by that I mean in terms of 7 compliance. Should we compromise, as I have seen in some 8 of these things where we say that the fact that the minority 9 involvement is not present in either the delivery or in the 10 RAG and that kind of thing, that it is oversight of nice 11 people and that we pass on? 12 I mention it here, and I think it ought to be out 13 openly and honestly. 14 DR. MARGULIES: Let me atisN@,or the specific issue 15 which you raised, the Secretary's letter. That information 16 was transmitted to every grantee and every coordinator 17 in the Regional Medical Programs with strong emphasis that it 18 be followed. That is not enough. I'@e have, as I indicated 19 in the last several sessions, placed great emphasis on 20 equal employment opportunity in Regional Medical Progr&mc, 211 as we have in RIEAPS. We have not -- and -you are quite right -- 22 raised this issue in my judgment to the proper level of 23 consideration in determining grant awards. 24 I would be completely sympathetic to making it a Fe iiepofters, Inc. 25 stronger issue and identifyin- it as one of the reasons for funding or not funding a Regional I,,Iedical Pro,,,-ram. We li,3.ve 2 seen improvement. lriiprovenicxit isn't enough. And this 3 is true in the range of areas in which grant funds are expender. 4 It is true in membership of Regional Advisory Groups, and 5 it is true of staff employment, both professional and 6- nonprofessional. 7 The figures that we put together recently -- and I 8 would like to have you see them -- indicate a level of 9 . employment which was quite striking the last time we had a 10 review of minority employment. And I think we probably have 11 those data available, and I would like to distribute them and 12 get your comments on them. 13 But this is an issue which I think has t,o not only 14 be looked at, but has to be given greater emphasis or vie 15 are mismanaging our affairs, 16 Now the other aspect of it, of where the funds go 17 and what opportunities minorities end underserved groups have 18 to gain benefit from a Regional It,odical Program, get us into 19 the question of how one is able to utilize RNII) funds and 20 what should be the mechanisms involved, I have been talking 21 to Dr. Duval, and I will be seeing him again later this 22 week, about this kind of a question as it relates to 23 comprehensive health plans. Under good circumstances 24 comprehensive health planning activities should be so ,Poiters, Inc. 25 developed that there is a true minority representation, so I that there is a s(-)Iection of priorities for the Community, 2 an identification of vjhat that coimnuiiit wants to get with y 3 what it is investing and what is being invested in its nome 4 by federal, state and local government. And the Regional 5 Medical Programs Should be totally responsive to those 6 identified needs. CIIP has not been able to produce yet that 7 kind of a structure. I think it should. 8 My own feeling, which is not generally shared, 9 however, is that not only should that be developed in such a 10 way that the total community interests are represented with 11 strong emphasis on Minority interests, but Regional Medical 12 progrwiis and other federal agencies should be bound by it. 13 Not just review and coiTLynent; I would favor a much greater 14 authority for CHP, because 1 do not believe that what we are 15 aiming for is going to be produced by the Regional Medical 16 Program operating as an independent a-ency, It is too much 17 provider dominated, which is the nature of it, and it is net 18 going to spontaneously seek Out, and even though it may try 19 it may not do it effectively, those kinds of inves tments for 20 RYLP which affect the principle that you have been stating. 21 I would be happy to see this Review Committee pay 22 a much higher level of attention to those issues. 23 IM. PARIM: Welip J.ii terms of what we are really 24 addressing, and this is in terms of focus and the kinds of Porteis, Inc. 25 emphasis, what roles and fate this plays in the evaluation 53 I of the programs and this kind of thing, it is a particularly 2 hazy area, fuzzy, if you will, because I think in terms of 3 utilizing the things within the Department of HEW that are 4 identified for some of these purposes we need that kind of 5 advice really before another cent is dispensed. We need 6 the advice of the civil rights compliance unit within HEW 7 as to whether in fact -- not,whetlier they have signed the 8 forms, but whether in fact these programs are doing what they 9 should be doing under I-MW guidelines, tinder guidelines of 10 various statutes, under the guidelines of the various -11 executive orders which date back now as long as the Eisenhower -12 administration. We do not know. And these are things about 13 whic h there certainly is neither obfuscation or quettion. We 14 need not search for these, and the niechanisri for providing 15 us viitli that advice is present and is a part of the establish- 16 rient. 17 What I am suggesting to you is that I think there 18 are some things that we could do with it. 19 DR. MAYER: Further comments? 20 Yes, Jerry. 21 DR. BESSON: I think Mr. Par s introduced a new 22 notion in the review process, one I think we should pursue 23 perhaps a little more vigorously, if those morning sessions 24' are going to-be more than psycliotlierapetitic catharasis 1 -Fedetal RcpoiteFs, Inc. 25 think they really have to be translated into direct action. Olt I I think it is not sufficient for us to platitu,-Iinous-ty 2 say that we need greater emplit@-i.s on this, and if I read 3 Mr. Parks' comments and the Director's aCqUieSCODCC to his 4 comments correctly I viould like to suggest to the Review 5 Committee that we do tal,,o the stop that is implicit in his 6 comments-and make -- and I would like to make this in the 7 form of a motion, Mr. Chairman, for Councills consideration 8 and decision -- that no RI.IPS program be funded without 9 prior indication of compliance of that prograir. with the civil 10 rights unit of the Department, and that a sine qua non be 11 established. And I would like to Put that in the form of a 12 moti.on for Councills consideration with decision at its 13 next meeting. 14 DR. MAYER: You are making a recommendation of 15 this Review Committee to Council? 16 DR. BESSON: Yes. 17 DR. MA7,T,@R: I need to have clarification, Jerry. 18 Welit is there a second before discussion? 19 MR. PARKS: I will second it. 20 DR. htl-tYER: I need to have clarification from staff. 21 I frankly have been assuming that th--t in fact was happening. 22 If it is not, then I think the motion is in order. 23 it? DR. IAARGULIES: Jerry, do you want to comment on 24 tiR. ARDY.-LL: The only thing I can say is to the, best Fe Repo( ters, Inc. 25 of my knowledge %what we are doing here I think kind of goes I back to your comment. I don't know the extent to which the desires of the administration are carried 'out by this 2 3 Department. And the only notice we have gotten to date is 4 the continuation of what Mr. Pari@s has just mentioned from 5 the administrator, and we in turn gave that to the programs. 6 I don't know if we move in this direction 7 think what you suggested, Dr. Margulies, is that we are 8 independent, we are one sho.w doing this. I don't know who 9 else would go to this eXtODt at this particular time,_. I 10 think we need to pursue this before Y,,e-- 11 DR. MAYER: Let me be explicit. I need to have 12 the question in order to answer -- you know, because if the 13 answer to the question is one way then the motion is in fact 14 appropriate. If it is not needed then we need to know that. 15 DR. BESSON: Mr. Chairman, in th e review of the 16 program that I have had for this session I have had no indication 17 that there has beeD compliance by a reviewing unit with 18 civil rights legislation as far as !LEW programs are concerned. 19 I would like that to be-an incorporated part of the materials 20 that are presented to me for Review Committee decision, 21 DR. MAYER: Well, that is a different motion, Jerry. 22 Then I wouldn't have had any trouble with it. Your 23 recommendation to Council was that they take the necessary 24 steps to insure that funding does not occur. Now what I have -Federal Reporters, Inc. 25 just heard you say is that -you would J.iko to move that this Review Coyti-,,iittee request that that compliance be provided to 2 then before they f-,o through the revieN-4 procesv,. liave you 3 changed your motioi)? 4 DR. BESSON- No, I haven't at all. I just added the-teeth that such compliance be a sine qua non to funding.. 5 6 DR. MAYER: Well, I am still unclear. Do you or 7 do -you not want to have that information before you.go through 8 the review process? 9 DR. IM@SSON: Yes. 10 DR. MAY-BR: Or do you or do you not want the 11 assurance that it is there before funding occurs? 12 DR. BESSON: Yes. 13 DR. @IAYI,7,R: So there are two different levels end 14 txio different issues. 15 DR. BESSON: I would like to have the information, 16 but if, the informatioii.doesn't represent compliance I 17 don't even want to look at the program. I would consider that 18 it is a sine qua non of program approval, and v@ithout it 19 that program not even be bothered to be reviewed. Does 20 that make it clear, @Ir. Chairman? 21 DR. MAYER: Yes, 'you are going to have to modify 22 the motion that -you made then, because what you in effect 23 from an administrative standpoint have just said is that you 24 want to have that compliance before the review process )s -Fe evil Repoi ters, Inc. 25' initiated. DR. BRSSON: Right- 2 DR. 14AYEP,: That is a diffc rent-statement than the 3 statement you made earlier. That's all I am saying, and 4 need to be clear what it is 'You want. DR. BESSON: That's what I would like. I would 5 like Council's de cision on that point. 6 7 NIR. pARI@: lie said the compliance report, and that 8 a certification of compliance be a sine qua iion, without 9 which condition-- 10 DR. MAYER: Somehow I am not coming through. 11 DR. BESSON: Perhaps you can state my motion, 12 Mr. Chairman. 13 DR. MAYER: What I heard, yc-irry, without writing 14 it doiyn, was your request for certification of compliance 15 and adequate review to insure-.-, the compliance occurred 16 was,a recommendation -you wore making to Council so that 17 that had been accomplished prior to any funding. 18 DR. BESSON: And ,-tdd the additional clause that no 19 funding be considered without such compliance. 20 DR. MAIRFR: All right, but that still doesn't get 21 at what I then he ard you say, is you don't even want it 22 to go through the review process until it is there, because 23 that's a different frai-ne of reference. 24 tM. PARO: Well, let's write it down. Repofiefs, Inc. 25 DR. MAYER: You see the point I Imi mt.,Ring. The point I am 2 NM. I)ARI@: We will taJe care of that. Let Is 3 try to write it down. The first point is -- again I don't 4 want to usurp your motion because I am only the seconder 5 of it. 6 DR. BFSSON: Well) I would add the third clause 7 that you just stated, that the pro.-ram not even be 8 reviewed unless such compliance is part of the information. 9 DR. IIAYER: All right, fine. I just need to have 10 it clear because those are trio different iF3SUOS. 11 DR. SCIIF,RLIYS: Is there a specific written directive 12 which is a checklist as far a@, what is or is not compliance? 13 I ask this from a sense of tiaiv(ity of instruction You 14 have talked about compliance. Is this a wr itten checklist 15 document. Dr. Marguiic,-z, do you have such a listirig. What 16 would the certification of co,,,npiic,-nce indicate? 17 DR. MAP-,GULIES: Noo all grants and contracts 18 of the federal government require civil rights compliance, 19 but I am not acquainted with any Ir,in(i of checl,.List ahich 20 would determine whether or not that conp@,ia,i)ce has occurred. 21 For example, every university which receives 22 federal funds has to have civil rights compliance Yihich would 23 cover a wide range of legislative acts. It is separate 24 from what air. Parlrs was also talking about was Reporters, Inc. 25 executive order, which is.anotlier kind of, but related# quest ol And I am not familiar my oviii ignorance with what 2 kinds of checkoff lists might exist and what kind of 3 measures have been carried out to confirm that compliance has 4 in fact occurred or prove that it has not occurred. 5 DR. SCHE@RLIS: Another point of information, how 6 would passage of this motion affect -your operation? 7 DR. MARGULIES: Herb says we would go out of 8 business. 9 DR. PAHL: So would every university in this 10 country. 11 DR. SCIIERLIS: Could -you amplify that, because that 12 is a very interesting response which I didn't anticipate. 13 DR. PAHL: Let me not COMMeDt as Deputy,pirector 14 of the program, but as an individual. I think all of us are 15 aware of civil rights acts and what has happened and what .16 has not happened in the country. I have only bbcn in the 17 federal government for ten years, and I wn not sure I know 18 what does and does Dot go on in compliance with all the 19 rules and regulations -for awarding grants and contracts. 20 I think what it is 'we wish to do and what we do 21 accomplish in the country are two different things. It is 22 my personal opinion that if this resolution were adopted 23 and implemented our program would not be able to operate at 24 all, because I darosg.,y that I don't knout a single community -Fedeial Repottets, Inc. 25 in the country that fully complies with the civil acts and 60 I re[;LiJetions, civil rights legislation of the country. I am 2 sure such cor-L,,iunities exist, but I.don't know of them. 3 This doesn't say we shouldn't strive to meet those 4 goals. But if one sets an ultimatum for the next 5 review cycle that no funds would be aN,;arded unless full 6 compliance were achieved it is my personal opinion, not 7 that of a program official, that this program and no other 8 program in the federal government probably would be able to 9 function. The highway program I am sure couldn't. The 10 Department of Defense couldn't. HEW can't. That is not to 11 say that we sh ouldn't strive toward it. But if it is an 12 ultimatum, I have been in several universities and a 13 least from my personal observations those universities would 14 not be able to receive another penny either if full compliance 15 with all the legislative requirements had to be met by the 16 time the next disbursement of funds occurred. So I will 17 be very interested to s ee what occurs. 18 What-I think me' do have is civil rights legislation 19 with appeal mechanisms, etc., built in. But as we all know, 20 even in the case of Virginia and its integration of sch ools 21 in the newspapers, it has taken many, man-y-years,and we are 22 still not at that point. I don't see how it is possible for' 23 R!YIPS in the next three months -to achieve national compliance 24 with civil irghts legislation. -Fcdeial RcpDrtefs, Inc. 25 I am not in disagreement with the goal. I am trying 6i I to look at it from-a vory practical point of view. I think 2 the subject should be explored, more should be done, but it has 3 to be done in the practical sense if we are to achieve 4 anything. 5 MR. PARKS: May I get a point of clarification? 6 Are you sayin,- the law should not be complied with? Is that 7 your position? 8 DR. PAHL: Indeed not. I want to make that 9 perfectly clear. 10 DR. BESSON: I3ut, Dr. Pahl, perhaps so,,,io of us 11 neither share your diffidence nor your somantit choice of 12 words when you use the term ultimatum, implying we are in no 13 position to use that kind of approach, implying further t at 14 it is going to take some tooling up. I think. that if we 15 hold the purse strings -- and I suppose vie do as a revieu, 16 Conuiittee, as we really are a policym,@ing body in advising 17 the Council -- then we would be negligent in our Leadership 18 role if we didn't do what we thought appropriate, if the 19 authority is truly vested in us rather than yourself and 20 Dr. Margulies, which I think the law asks us for, then I 21 think it is our choice and the staff really must comply with 22 the policymaking body. 23 If I am incorrect in that assumption, Dr. Pahl, 24 perhaps I should stop right here and perhaps -you can either I,,al Reportets, Inc. 25 reassure Me-- DR. I'JKRGULIES: Niay I respond to tliato because, the Review Committee is not a POli.CyMaltiDfr body. The Review 2 3 Committee is created as an administrative device to support 4 the activities of the Council, The Council is a policyniakiiig 5 body and is advisory to the Secretary. This is a review 6, committee. 7 DR. BESSON: I accept that. We are advisory to 8 the Council, and we would request Council determination on 9 this as a policy matter. But I think initiation of policy 10 change may occur here for Council concurrence. 11 DR. MARGULIES: Certainly, but that is not the saiae 12 as being a polic@ymaking body. 13 DR. BESSON: No, no. 14 M. t!AYER: Sister Ann. 15 SISTER ANN JOSEPIIINE@: Yes, I would like to ask 16 Dr. Pahl what steps are taken to review compliance, I mean 17 is there any supervision of this as appropriations are made, 18 the degree of compliance? Illhat steps are taken to review the 19 degree of compliance? 20 DR. PAIIL: In our program to the best of my 21 knowledge none are being taken. perhaps staff can inofidy that 22 cor,,unent. Jerry. 23 DR. ARDFLL: Except to the point that there is a 24 published list of tlioe organizations that are in compliance, ,-Federal Reporters, Inc. 26 and if they are not in compliance we are informed and we do 63 not make grants to them until they are in compliance. 2 DR. MARGUI,IES: I think one.n@ust recognize that 3 the whole process of reviewing civil rights compliance 4 involves a very large segment of the government which I think 5 most people would recognize has not been able to do all that 6 it would like to do and all that should be done, But I 7 doubt that you could read the newspapers for a weel@ without 8 finding evidence of a challenge to civil rights compliance 9 in schools, in hospitals, in construction work. But it is 10 a part of BEWP it is a part of DOD, and the civil rights revie%e 11 and enforcement activities are of tremendous political 12 prominence, so it could hardly escape one's attention. But 1 3 we areIa part of the IT,,IY civil rights compliance Ekgtivities, 14 SISTER ANN JOSEPIIINE: I raise this question because 15 I know that we have many, many fine -- just as in any kind 16 of business, we have many, many very fine policies, but unless 17 there is surveillance of the implementation of the policies 18 their formulation may simply be a political move. An d I 1 9 think that as we are looking at Regional Igodica Progr n 2 0 services we need to ask whether we feel at this point in 2 1 time that we a-re looking at one of the weaknesses of the 2 2 program when WO say %ye have a policy that applies not only to this program, but to every federal program that is being 0 funded, and 'yet we are not exey.-ting good in,'-nv.-ement 24 t- Federal Reporters, Inc. 25 supervisory control to see that the. policy is implemented. I 64 I This is as I interpret the question. 2 DR. PATIL: I would like to agree that v4e are not 3 exercising the degree of maiic-,.gowent surveillance and 4 control that we would like, This also holds true with other 5 areas, and that is in the management of grant funds. It also 6 holds true with copyright laws. Again it comes down to a 7 question primarily of not what one would like to do, but what 8 one is able to do. 9 There are other sections of HEW that are large and 10 have the responsibilities for carrying out surveillance, appeals 11 We must- in all good conscience depend upon some other unit 121 of the government than ourselves in a very practical sense 13 because society is interrelated and we can't do ev@,ryl;hJ.n,,-. 14 Again that is not to say that one is is disagreement 15 with the goals. But I think tir. Ardoll would agree that 16 every grant and contract that emanates from R,@IPS has many 17 conditions attached, and in all honesty I don't think any 18 of us in this room can say that vie provide surveillance over 19 most of the conditions-under which v.,e make the grant and 20 con'trect awards. There is a mechanism by which if matters 21 come to our attention that there is noncompliance in this 22 and other areas then there are routes, mechanisms, etc. 23 1 do not see us in practical terms having the 24 wherewithal to carry out what the Revic,@w Con,.niittee is -Fedc,ial Reportefs, Inc. 25 suggesting, however desirable' it may be. DR. IAAYER: Dr. White, 2 DR. WHIM: I think this kind of resolution clouds 3 our role. I think we axe mixinp,- up what our purpose in life 4 is and vihat the purpose of other people mi-ht be in 5 reference to this particular point. And it puts Trio in the 6 position of having to choose between the consequences 7 of being a bigot or the man from Lamanchia. I don't believe 8 this is an inappropriate concern by any means. I don't 9 want to be classified as a bigot. On the other hand, I 10 think it is totally inappropriate for us to be acting 11 as a policeman, which is what we are trying to do. 12 DR. MPYER: John. 13 DR. KRAWLEVISKI-. 'Let me just carry on with that 14 comment a bit because it is along the lines of something I 15 wanted to say before. I thiInk one of our real probicris is 16 trying to determine the role of this committee here. if 17 we see Council as a polic@ymaking body and then ve see the 18 RMPS staff carrying out that policy and implementing it 19 throughout the regions, it seems to me then our role is 20 one to look at the structure of these regions to try to 21 assess their ability to formulate and carry out progrc--vs and 22 advise in that capacity. 23 Now it is disturbing to me in a way that we find 24 the funding levels are only about 65 percent of what vie Federal Reporters, Inc. 25 recommend, because we look at-tlic capacity of a region, Nlic 66 I reco,@-iinend the level of funding tliot we believe they can 2 handle. In nany cases I guess Council may alter that a bit, 3 but essentially.establishes a level along those lines, and 4 then sometime later when the real decision is made apparently 5 when the money is parceled out and 'you determine who should get what., and the decision at that point I think is the 7 crucial one, and the factors that are taken into consideration 8 at that point are the factors I think that are the important 9 ones, whether they concern compliance i7ith certain laws, 10 whether they concern whether or not the region has developed 11 goals and objectives that are in line with national 12 priorities, I would like to have -you comment on the kinds of 13 things that you take into consideration when you give that moncy 14 out. 15 If in fact you are acting in a capacity w re -you 16 believe that these regional offices should be very closely 17 aligned with your central staff here and that you have sl)--ci'Li( 18 things that you would like to have them do, and if they do thal 19 you are going to give them money for it, then I think 20 probably this Review Committee is inappropriate and that 21 what you need is a body of individuals that might site visit- 22 programs and give -you a written report on it as to what their 23 capacity might be or their estimation of their capacity, and 24 then you use that when you make your decision, but disregard i-. ,-Federal Reporters, Inc. 25 if you v;ish, and parcel out the money on the basis of 67 specific thiDgS that You would like to have accomplished and 2 whether that management team is accomplishing it or.not. 3 DR. MARGULIES: Well, that statement I think is 4 the crux of what we have been talking about. 5 Let me go first to the question of why we don't 6 fund at the level that has been approved. It is pretty 7 simple. We did this, we took a look at what would happen 8 if we aNvarded grants to all pro-rams at the levels which have 9 been ap roved by Review Committee and approved by Council, p 10 it would far exceed our budget. So it Iis simply a matter 11 of making adjustments on the basis of what funds are 12 available. 13 The question of how we make that docisiop the 14 answer to that is determined by what kind of relative ranking 15 and what kind of input is made by this Review Committee, 16 which in fact is the most critical, formalized, careful revieN@, 17 process that we have available. 18 Now the next point that -you raiE;ed, of havinp, some 19 kind of a process by which we determine conformity versus 20 something which determines whether or not this proftram 21 reprosents.an effective institution for the region, is one 22 that represents the range of differences vilxich we see here 23 present. Len was sayin- that he sees pro-r@- coiiing up 24 with the right wo rds, they parrot the kind of sounds which are --Fedeial Repotters, Inc, 25 you being made at the national level. It is Y,,iy belief that if 68 then follow the general statements which are inc-de at the 2 national level with a specific guideline as to what each 3 RMP should do, that that is exactly what each RMP should do, 4 aW we would be deciding in the Parklevin Building what should 5 be done in every Regional Medical Prorrain. I don't think we 6 have that ability. I think it would be a sad mistakei and 7 I guess the real difference lies in how general our descriptior 8 of goals should be and how mrithin those generalities the 9 review process should be carried out. 10 I understand -your anxiety over it. For what it is 11 worth, I think this review process, considering the fact 12 that we are trying to describe a now institution in 13 shiftin,,7, times and with heavy domp-nds being pla,--od'%ipon us, 14 works remarkably NY611. I think if you.were to set up a 15 different kind of system which is analytical and careful it 16 would come out very close to the kinds of determinations 17 which this review committee is making. If we get.very e@@'piicit 18 about it then we might just as well switch to some kind 19 of formula grant and see if'the program is doi ng exactly what 20 we told them they ought to do, in which case I can't see 21 much point in having a Regional Medical Progtwn, 22 On the other hand, if we want to go to a series of 23 projects scattered around the-country there is also no need 24 for a Regional Medical Program. I%le can simply make the -F (Ipoftels, Inc. 25 grant awards to the project directors and carry it out in a I scattered fashion. 2 Somewhere in between is structure which manage' 3 to elicit a sense of coordination and of general direction 4 and determination for the providers of medical care in the 5 region. They base their actions on a series of analyses and 6 judgments which lead to a finite program. They do this with 7 varying degrees of skill, They are hampered at the present 8 time by the need to move from old patterns to new ones. .9 But in general I think the process is representing 10 region by region the emergency of an understanding of what 11 they should be. 12 For example, just to add one more comment to it, 13 if 'it is true that comprehensive health planning plays a 14 significant role or should play a significant role in what 15 an RIIP does or what other federally supported activities do, 16 then to have a strict kind of description of what R@ff) is t- ii as a theory, when the fec 17 based upon h, t is that B 18 agencies and A agencies are highly variable, Nyouid be a sad 19 mis t alce I can point'out areas for you, and -you know t cm, 20 too, whore there is a powerful B @-ency in an R@IP. And I 2 1 can show you the reverse. And the circumstances which 22 prevail in those communities are totally different. And they 23 need to be measured by the kind of specific site visit and 24 review Mechanism which is carried Out lie re "-r'cdctal I?Lpotteis, Itic. 25 It is not a pro,-,ran, like a University which I so many p3ople, graduates so many people. It doesn't h@zve 2 this kind of a finite function. But I think its purposes are 3 becoming clearer and clearer. 4 1 think this Review Committee from my point of 5 view is an essential part of the activity. If the Review 6 Committee decided that it didn't need to do what it has been 7 doing we would have to go to the trouble of forrii.ng another 8 one, because it adds tremendously to this review process, 9 and at this point I can't feature a way in which we could 10 operate intelligently and honesti y without that input, 11 including all of the differences which we have this morning. 121 DR. MAYER: We have a motion that is on the floor. 13 Let Ins see if I can recapture at least, if not the,,precise 14 wording, the intent of the notion -- that the motion 15 recommends to the Council of the Regional Medical Program 16 that the Council consider the adoption of a policy which 17 would insure that before funds-are awarded to an individual 18 Regional ?,Iedical Program that that individual RMP was in 19 compliance with the Civil Rights Act, and that furthermore, 20 that they further consider the establishment of a policy 211 which would insure that regions not be reviewed through the 22 existing review process until such clarification of compliance 23 were there. 24 Now does that catch it or not? -Federal Reportets, Inc. 25 DR. ITESSON: Yes. .1 L DR. MAYER: Okay. Further discussion of the motion? 2 DR. WHITE: I wonder if theloriginater of the motion 3 would define compliance for us. 4 DR. MAYER: The question was what is meant by 5 compliance. 6 DR. BESSON: Is there a body in HEW that is charged 7 with the authroty of definition? 8 DR. IIARGULIES: Yes, the whole structure which 9 enforces the Civil Rights Act has measurement of compliance. 10 DR. BESSON: Is there a division that is assigned 11 the responsibility of doing so for HEW? 12 DR. MARGULIES: Broadly in ITEIV, yes, for all- of HEIV. 13 There is in education, there is in health, there in 14 welfare. 15 DR. BESSON: Then I would ask that the appl ea on 16 be presented to the Review Committee with the definition 17 outlined by that group. 18 MISS HERR: Maybe I &in getting to a simplified 19 version of this, but a ball park figure -- and as I have 20 been reviewing regional medical prograi-,is, making site visits, 21 etc., I tend to come to the conclusion that they are complying 22 if there is an equal representation percentage in the 23 people involved and in the staff as we find in that particular 24 region. That is the only measuring stick I have had to go oil. Federal Reporters, Inc. 25 MISS ANDERSON: Includes females, too. 72 I MISS yEr,.R: ivoill I can't argL]O that. You know, I 2 don't have much -- but, for examples there are Regional 3 Medical Programs in which there are ethnic groups, quite 4 sizeable ethnic groups, for which I have seen no 5 representation. There are others I have seen them very well represented. So this is the way I have been measuring. 7 DR. IIARGULIES: Fell, you realize that this would 8 have to include compliance on the part of the grantee agency, 9 which means that every university, every medical school, every 10 state society which is responsible as a grantee agency 11 would have to show compliance with civil rights in all of its 12 contracts, in its construction, in its employment, in its 13 staffing, in the way it handles its faculty, and at the 14 present time this also includes proper identification and 15 advancement for women in employment or on faculties, which, 16 as you know, is quite an issue in itself. 17 DR. BESSON: I don't care about the details. It 18 is the principle. 19 DR. MAYER: joe. 20 DR. HESS: I wanted to ask, Jerry, if you had 21 any time deadline in mind in making this motion, and if sOp 22 the administrative mechanism for dealing with that deadline 23 in terms of ability of the arm of the federal government that 24 deals with this question to get in and participate in a '--Fedetai Repofters, Inc. tificatioii 25 meaningful way in this process so that proper cer could @ done in keeping the review cycle and process-- 2 M. BESSON: Well, Dr. liess, I am sure that v@,e couio 3 discuss for another week the reasons v,,hy it is impossible to 4 accomplish or implement this motion. But if the Council 5 decides this, then it is for staff to have the problem of 6 implementation. I am interested in the principle involved, 7 and I am interested in assuring ourselves @ a review 8 committee that this question is considered by Council; and 9 naybe the details make it impractical, but this is a 10 question that we are discussing, whether the weights that are 11 assigned he re for judgment of the rankin- of on individual 12 region,could not have minority interests changed from the 13 weight of 7 to a weight of'16 as a sim, qua non ,,That i s 14 all. now that may be impossible to implement. But if that 15 is the case then staff will hwe to decide that with 1 6 Council. 17 But I am not bei,n- coy when I say that is not my 18 problem. It really isn't. I am interested in laying out 1 9 the philosophical basis for this principle. 20 DR. ttAYER: Further discussion of the motion? 21 @M. ARDELL: I would like to say I wonder if there 22 isn't a little different area of concern here, and that is 23 as it relates specifically @o the R.T,iP, because really 24 there is no application that can be processed in this -Federal ReportLis, Inc. 25 Department that does not comply ",itti Title VI as one of the I assurances. It is in the boilerplate in every application 2 that we review. And I think you are really concerning 3 yourself more with do we take a hard look at what the RMP 4 is saying it is doing in the way of providing for minority 5 involvement, minority support, et cetera, 6 Now if that is not so, then I think what you are 7 asking us to do is to really go behind the assurance that the 8 Department has already received from every applicant to make 9 sure in fact that this is true. 10 DR. BESSON: Well, I am not satisfied that-that 11 is enough. I think as regions read the-tea leaves daily 12 and I sea sure they do try to decipher the vibrations that 13 are emanating from this august body and its counterpart, 14 Council and administration, I am interested in sending them 15 a message, and even if 'we gain no more than 10 percent or 5 16 percent or 2 percent, i percent enhancement of this effort 17 by means of this message, I think it is in the right 18 direction. If we gain a hundred percent that would be fine, 19 too. 20 DR. MAYER: Further discussion of the motion? 21 DR. SCHERLIS: Dr. Besson, -you stated 'you are 22 interested in principle, yet as I read your motion it is one- 23 of exactly logistics, 1.)ecause.-you are saying either they 24 are in compliance or not, and if they aren"t then that's it Fe CIII RePo(ters, Inc. 25 as far as funding or even consideration of review. And I 73 I ivould wonder whether or not -you could redefine your motion, 0 - 2 perhaps after a coffee break, to bespeak more to the principle 3 than the logistics. 4 DR. BESSON: No, I think the principle has no 5 meaning unless it has the teeth of funding. I think that 6 is the only weapon-- 7 DR. SCIMRLIS: I was just using your definition of 8 your motion, and you recognize it has having teeth in principle 9 DR. DESSON: I do indeed. Our only leverage 10 is funding, and unless we can speak with funding vie have no 11 voice. 12 DR. MAYER: Further comments? 13 MR. PAR.KS: Well, I will make one other commelit. 14 The total responsibility for monitoring this does not rest 15 with the officer in the Secretaryls office that is char-ed 16 with -- or the civil rights compliance unit but there 17 are some very specific federal agencies that not only oversee 18 this, but will help you implement, and that is their 19 specific charge. The Civil Rights Commission is one. The 20 Equal Employment Opportunity Commission is another. And 21 there are various state and other agencies that would impact 22 upon your universities and various other kinds of operations, 23 and that is a matter that I would leave to some extent to 24 their expertise; and cortaini -y in terms of burden it should @-Federai Repotters, Inc. 25 represent only a mythical burden in terms of what this staff 76 would have to absorb. 2 I would think in terms of notice that they have 3 had notice about a law that has been passed or an executive 4 order that has been published ever since it has been uttered 5 either by the Congress or by the President, an(] certainly 6 presumably all factions of society, both donors and donees, 7 public and private, have had notice that the-law is there 8 and understand that the law is to be complied with. 9 Ail we are ,Asking here is that we come out with a 10 polic position which clarifies what is or Y-that should not y 11 be done, and I think this is not just a thing that we are 12 going through here in terms of something nice in principle. 13 It is indeed an obligation. And I think most of tile people 14 here, certainly every one of your public officials, including 15 you, Dr. liarguli.es, and your staff people, took an oath 16 when they embarked upon employment as a federal employee. 17 I think this motion that is here, it sii-.iply calls.upon them to 18 live up to that oath, calls upon the Council to take a 19 policy v7hich would encourage that. 20 DR. IIAYER: Dr. White. 21 DR. WHITE: I think the passing of a resldtion of'tl,,is 22 sort simply strengthens the concept of tokenism. I think 23 our responsibility along these lines is to make sure the 24 program the Regional I,.Iodical Pro,,,ran, proposes attends to the FcdL(,Il Reporters, Inc. 25 needs of these people. DR. IAAYER: 'Dr. Fless. 2 DR. HESS: I have somo real trouble with the wording 3 of the motion as it now stands. I think if this were accepted 4 literally the way it was stated that it Would be much more 5 destructive than it would be constructive. And I am totally 6 in sympathy with the principle N,,hich -you are trying to get 7 across, but to say that there @,-ould be no funding Y-iould 8 be destructive, it seems to me, of many of the good things 9 which are going on in RI,@IP's which are indeed reaching and 10 helping many of the very people t hat -your motion is saying 11 they are going to help.. So I will have to say the wording 12 of the motion as it now stands is one I cannot support even 13 though I ain in favor of what I think is the principle. 14 Now if you viant to modify that and say further 15 increments, %7j.thout an absolute cut off -- the implication 16 of your statement is that there would be absolute cut off of 17 funds and the dissolution of Regional lledical Programs, 18 and I do not think that would be constructive action, But 19 the message that you axe tr.ying to get across it seems to me 20 would get there by sonic further emphasis on this as part of tl-e 21 review criteria and a modification of the rate at Nyhich 22 new funding is granted based upon heavier emphasis on this 23 particular criteria. I think you got the behavior that -you 24 are looking for, but without destroying viliat is already there. efli RL'Poiters, Inc. 25 DR. BESSON: Ilow would you modify it? I will I accept a modification if it is in line With !3LIpport of the 2 principle, 3 DR. TIESS: Soniething to the effect that consideration 4 for further increments of future funding will not be 5 considered until there is assurance that the region is in 6- compliance with the Civil Rights Act, or however that might 7 be worded, putting the emphasis on the further increments 8 rather than all funding, which is the way I interpreted your 9 motion. 10 tM. ARDE-LL: You see, that stateraciit can be 11 questioned because we wouldn't make a grant unless so I 12 think what you are really asking us is to go behind that 13 compliance and see really if it has been implei-tieiite,o. 14 DR. MAYER: Vile will tv,.Ize two more comments and then 15 we are going to vote on the. motion. 16 DR. SCIM,13@LIS: Are you telling us that every region 17 states that it is in compliance? 18 MR. ARDr,,LL: Every grant program must be, before it 19 can be funded, in compliance with Title VI of the Act. 20 being as)-ed to vote on i DR. SC'r!EP,.LIS: Tlienvihat we are 21 a modification of this. Do' we, investigate to see if they 22 are indeed in compliance? Because on the one hand %ye have 23 written statements testified to by responsible-- 24 DR. LEWIS: I think I share the problem with Fedctal Repoiters, Inc. 25 Dr. White or that Dr. White articulated very nicely, insofar I think if you vote again!?.t any such resolution you are at 2 risk of at least upsetting your own emotional feeling towards 3 bigotry, and I feel personally that the obstruction that 4 we have been discussing right here is virtually impossible for 5 me to interpret since I really don't know what any tiio people 6 around this table have meant when they talk about conl)iiance 7 and what kind of details that really nBans, and I don't 8 know whether this intent at.abolisl-iing one form of prejudice 9 might not actually allow'for the exercise of other forms 10 of prejudice if we become highly detailed as to whether a 11 region get all of the money due to it or not. And what I 12 would really rather see is a test case; that is if a region 13 that isIup for its triennium is one that Mr. Parks,pr 14 anyone else at this table is questioning in terms of having 15 such a low score in this particular category as to whe@Lher 16 it actually is in compliance with the Civil Pvight.s Act, then 17 I would like to bring that up to task. 18 But to make this across the board a motion is 19 to me P. difficult thing to fathom because I really don't know 20 how I can vote for it, but I don't know how I can vote 21 against it.. 22 DR. IIAYER: Dr. Thurmaii, 23 DR. TIIUR!.IAN: I think that many of Lis share the 24 concern of being labeled bigots, and for that reason I would eporters, Inc. 251 to propose a substitute motion, and this would be to go back I to what Jerry said initially, to propoFe that we ask -tile I for permission to let us as reviewers consider this 2 Counci 3 in our site visits over the next three to four months, about 4 how compliance can be adjudged, because we have the 5 prerogative as site viewers to come back and say that 6 piece of paper that you signed is a piece of garb@ end vie 7 want some officer to investigate. This would be a much 8 more meaningful approach then for us to got hamstrong at 9 the present point in time with a motion that some of us 10 find we have to vote against, but yet we don't want to be 11 labeled bigots. 12 This would give us a point of four months -- and 13 I think 1.1r. Parks Could live with four months, having lived 14 with it for X number of years -- to let the reviev@,ors as 15 they go to a place say I'@,,hat does your statement of compliance 16 really mean, you sigiied it, what does it really mean," 17 because we still have the obligation as site revievicrs to 18 request a compliance visit be made. That is our rerogative a3 p 19 the site reviewer. 20 So I would offer that as a substitute motion, not 21 as a delaying action, but rather than keep from being labeled 22 as a bigot, as Dr. White and otherssaid, because I have to - 23 vote against your motion as @t stands. So I offer that a 24 substitute motion. Repofters, Inc. 25 DR. BESSON: Weill 'I would be wiiiin- to accept that as a substitute motion if we do have some indication on 2 the review form that compliance is indeed more than just 3 pro forma. That is really vihat I am interested in. I think 4 we have a responsibility to determine the accountability of 5 a region for compliance. I don't kno@v that this is being 6 done. I don't see it on the portion of the documents that 7 I reviewed at any time. And if such a statement could be 8 incorporated then I would be perfectly satisfied. 9 tM. ARDELL: There is an assurance in every 10 application. .II DR'. MAYER: Let me see if I have caught the 12 substitute motion then. It is up to both the initiator of 13 the motion and the seconder of the motion a.-, to wllgther they 14 will accept the substitute motion or whether they will 15 not, and we will vote on the original motion. So I gather 16 the intent of Dr. Thurman's notion Nyould be that we would 1 7 recommend to the Council that the review Committee a- it 18 participates in the review process be encouraged by Council 19 as a matter of Council policy and as an indication of 20 Council policy to give particular attention in their review of 21 the program, both in site visits and in this cowinitteog to 22 the issue of compliance with the Civil Rights Act, and 23 I think that is essentially it. 0 24 DR. TIIURMAN: And if. question arose we could ask @e-FL,derat Reporiefs, Inc. 25 for a compi iance officer to visit. 82 DR. ITAYER: And you heard that if question arose 2 that we would have the right to ask for a compliance visit. 3 DR. BESSON: Could we after that have some 4 documentation that this has taken place as part of the 5 material presented to us without accepting it tacitly? 6 DR. MAYER: The implication being, Jerry, that 7 each site review process -- the intent of the motion would 8 be that each site review process would carry out the motion 9 and document that they have in fact carried it out. 10 DR. BESSON: Yes. 11 DR. MA'ITR: Is that clear? is that an acceptable 12 substitute motion? 13 DR. BESSON: Yes. 14 DR. MAYER: Is it acceptable to you, Mr. Parl,,s? 15 tm. PARKS: Well, 'with this exception. I t take 16 it that it does Dot mean that we should really dicker Nyith 17 whether they compiled with what the low is or not. I grather 18 that is not at all the intent of this motion, because there 19 is a requirement that-there be affirmative action, plans, 20 various other kinds of things which are very specific. Ts 21 that-- 22 DR. THUITIAN: That is correct. 23 IM. PARKS: I will go along with it. 0 24 DR. MAYER: Does everyone understand the substitute @-Fcderal Repoiteis, Inc. 25 motion? it? I DR. SCHERLIS: Could -.you piea-ge repeat 2 DP,. THAYER: Wolip lot vie try it again. That 3 this Review Cor,,mittee is reconii4ionding to Council that 4 Council establish a policy in which they instruct those 5 participating in the review process, whether that be site 6 visits or this review activity, that a special interest be 7 given to, and attention to, the issue of compliance of 8 the individual regions with the Civil Rights Actv and that 9 as a part of the review that documentation occur in each 10 and every instance that that has in fact occurred in the 11 review process. 12 MISS I 13 DR. LIAYER: okay,. third question, 14 DR. IIIN@TAN: The third question was whether renal 15 programs funded by the re-ions will come out of their total 16 budget or out of a separate budget. The review and funding 17 will be done on a semi-separate basis, but it will be their 18 total bud-et dollars-When it goes back to them in the Advice u 19 letter. Conf6sing? 20 In other words, if region X has a kidney promrain 21 approved for $50,000 and their.total budget is two million 22 dollars their total budget is two million dollars, thon 23 the fifty thousand has to come out of it. In other %vordsp 24 the total award includes the kidney dollars. I Repotters, Inc. 25 s of freedom DR. 1.4fAYER: Do they have the same degree with it after they get it that ttioy have with the other? 2 DR. IIINMAN: You mean in the anniversary triennium 3 sequence? 4 DR. IIAYER: Lot me give you a for instance. This 5 group decides that it approves a million and a half for 6 a region, and it also has a half million dollar kidney 7 proposal which the ad hoc review group revievm and think is 8 fine and we think is fine and Council thinks is fine, and it 9 has an award of two million dollars. All right. What I 10 am saying is can they, if their original proposal had four Millie 11 dollars in it and we only approved half, can they take 12 that half million dollars of renal money and pump it into 13 somethin- else, or have they got to pump it into kicneys? 14 If you excuse the pun. 15 DR. HINMAN: I really doii't know the ansv..,cr to 16 that question. 17 DR. W.AYER: Well it is an important question. 18 DR. IIINMAN: The question that was asked, Herb, 19 was can a region take kidney money out and pump it into 20 other programs. In other words, if there was a total award 21 to a region of two million dollars of which $500,000 was '22 kidney money, could that RAG then pull 1.00,000 out of that 23 back into other program areas. 24 Repofteis, Inc. DR. PAHL: I think we would want to have a request 25 for approval come in to Rl!jPS for a major change like that. I DR. HII\l@IAN: Is tliri.t any different from any other 2 major program change? 3 DR. IAAYER: Now lot me -- it is different. Maybe 4 r don't understand the ground rules. All the question I 5 an, asking, Herb, is when we send back an award we send it 6 back with some advice and then we delete some projects, but 7 in essence we usually approve most of the projects, et cetera, 8 that they have in it, and if that is four million dollars 9 worth of stuff and we gave them two million dollars, it is 10 my assumption that what the regions are now doing is coming 11 back in to you with a proposal that says okay, thisis how 12 we are going to spend the two million dol ars an -you 13 allocate it, And you say okay, si-n off. 14 Now what I am saying is if that goes back and a 15 half a mil of that two mil is kidney disease and they come 16 back in with no kidney disease in that project, or only 17 200 thou of kidney disease in that project, do you treat that 18 any differently than anythinp, else. 19 DR. PAHL: Jerry is shaking his head. He may have 210 sorpe personal experience. 21 IM. ARDELL: Not really personal. I was thinking 221 that again it boils down to what is considered a significant 23 change in the scope of the program as it was determined to be 24 funded, and if reducing a sizeable amount of money going Fleeportefs, Inc. 25 to ki.dney-into soi-aothing else I would think that our review I process -,houlcl at ie> got the bl.csf@ings of the director of 2 the service for moving in this direction. I think tlit@t is 3 probably open for discussion. But that. is tbo intent ol@- the 4 whole system as I have interpreted it myself, that significant 5 changes really, we ought to be informed in advance rather 6 than after the fact. If they are lef@s significant then I 7 think that they do have the prerogative to move ahead and 8 just inform us after the fact. 9 DR. PAHL: Well, I think what Jerry is saying is 10 what I thought I was saying, that -we are not treating it 11 differently than any other major change, but we will consider 12 that, I would believe, to be a major change. 13 DR-. IFAYER: Ed. 14 DR. IXWIS: I'm reassured that the word categorical 15 is c- ity in these chambers, becauseiit saves onsi.dered a vulgar 16 me using a lot of other words. The thing that tickled me 17 about the answer from CouDeii was that Y,,e had a real problem herc 18 the last time and we asked them a question Y,,hich zunourits 19 to "is this po'n black or white," and they cqme back with 20 the answer "'yes," which is absolutely right. But I take it 21 from Dr. Margulies that kidney activities will account 22 for 8 to 8 and a half million dollars of this 135 million 23 dollar budget for this fiscal year, that there is some 24 categorical consideration to the way in which kidney projects -et Reporters, Inc. 25 are funded, and I would like to have clarification of that I specific point. 2 1 just wonder if there vl,9-13 someone who was at the 3 Council rieeting v.-ho is a,,,7are of v,,Iiotlier they really took it up 4 as that specific point or whether they indeed took it up as 5 is this pen black or white because this we knew aireL)dy. 6 DR. IIIIJIJAN: Well, Edl c@c, 'you know, there are 7 certain constraintsupod the allocated dollar that corie to 8 RMPS even thouah they are noncatcrox,ical, specifically the 9 AHEC and the 111,10 types of constraints. The kidney is not 10 a constraint in that same context, but it is a level that 11 appears to be in the context of the total R!@IPS p'rogra--,i 12 and the total request coiiing in fropi the regions, a figure that 13 is a fundable figure that is discussed between R@ff)S and the 14 office of the administrator and the various other parts of 15 the bud-et cycle. 16 That is a vague answer, but the process is not as clL--c,6i 17 and crisp as is the pen black or white, At the end of this 18 fiscal year it is our anticipation that the total dollars 19 that could be identified as going into kidney will'be 20 in the order of magnitude of eight to eight and a half million. 21 That does not mean that we are setting out to spend eight and 22 a half million dollars. 23 Maybe it would be appropriate to talk about how 24 We intend to handle the review process of kidney at. this *1 Repot ters, Inc. 25 stage instead of later. 95 I As was stated I think at the last review committee is 2 meeting if not, it had occurred or was occurring by the 3 time of.the Council meeting, the ad hoc renal panel is not 4 meeting any more. It had its last meeting early in September. -5 The idea that was behind this was Dr. Margulies' desire to 6 include kidney as well as the other programs in the total 7 regional development activities of a particular region. 8 However, because of some of the peculiarities of the renal 9 disease funding necessities, some of the gaps betyieen the 10 state of technology and the delivery in many areas, it will 11 still continue for a period -- I don't know whether that is 12 one year, six months, or two years to be handled i n 13 a semi-separate fashion. 14 lye are working on the guidelines at this time, and .15 they will go something like this. lYtieii the renal group i.n 16 a particular region has an idea and begins to discuss with the 17 local R!-.P? that they would like to submit an application 18 or proposal for support of their program the RMP is to refer .19 them for consultative assistance to RIIPS. Someone on my 20 staff will assist them in explaining the guidelines that are 21 appropriate at that time, and new guidelines are being written- 22 to update the November, i970 ones, and advise them as to 23 whether the idea they have wQuld seem to be at least in the 24 realm of activities that are appropriate for the limited Repor tet sInc. 25 dollar that RIIP has at this time. 96 .1 If they continue -- they can at that point decide to 2 continue and submit a proposal or not. It is their decision, 3 If they do submit the proposal to the iocaJ. RT@IP, the local 4 RMP will be instructed to have a local technical review, 5 it will be recommended that they include exl@rts from outside 6 their region, but that will not be mandatory, and we will 7 be maintaining a list if they ask for assistance here to 8 give them names of people that could assist on this local 9 technical review. 10 Following the local technical review it will go 11 to the Regional Advisory Group the same as any other element o'@ 12 tlio Rllk'P program. It %will then be submitted to the Regional 13 Medical program Service, at which point my staff will'be 14 asl@ed -- Bob Chantbliss's staff will be asked for two - 15 certifications that will go N,.,i.th it to the Review Cortiriittee, 161 i@e.t you. The first certification is as to the adequacy 17 of the local technical review. In other words, whether in 18 our judgment it was an adequate review on the basis of the 19 documentation furnished by them, that the people that 20 'reviewed it were indeed competent or I shouldn't say 21 competent, but at least should have been included in a 22 review committee and whether they did review it, and that 23 this was considered by the RAG, the recommendations from 24 this committee. epoftefs, Inc. 251 The second certification would be as to the adequacy I of that RIIP to administer the pro-r,?.jii that is requ 2 And that gets to the question that I think was behind 3 Sister Ann's question, and that is whether this would be so 4 skewing to the local region's pro-raiii that they could not 5 effectively carry out their total program activity and 6 administer the kidney one. 7 This certification or absence of certification 'would 8 be before you as part of the packet that -you %,ould have for 9 the review of that particular region, and it would then 10 stay in the cycle. 11 DR. LEWIS: Can I respond to that? 12 DR. MAYER: Yes. 13 DR. LEWIS: I have to articliletemy response in the 14 knowledge that I am assuming an attitude of general 15 @iligeronce and will probably upset a very loiigstandin- 16 happy relationship with Dr. Hinman, But I really must 17 look upon -- Dr. Scherlis wants to turn my microphone off 18 I must look upon what -you have just said as a very naive 19 approach to spending a limited ariount of funds in a field 20 that requires a lot of money, because it is very clear 21 that the ad hoc review panel was originally formed because 22 of the requirement of technical 9,ssistance, but also because 23 it appeared that there needed to be a body that Nyas able to 24 determine more than local activities. That is, there had RePoi teis, Inc. 25 tote an overview as to how much kidney activity was going on around the country or in the -treas surrounding a given rc-f_!-ion. 2 liow it see@- to me that what we have done is this-. 3 I honestly believe in view of the fact that R.Nii)S has 4 articulated decentralization that something like a central 5 ad hoc review committee is an embarrassing thing, politically 6 embarrassing particularly. But I think that what has been 7 done is this -- that v@ are noNi asking the regions to 8 construct their own programs which they are doing anyway. 9 In order for them to even construct the program they have 10 to include virtually every element of expertise in the renal 11 field in the region, otherwise it wouldn't be a regional 12 program. So obviously the region's program will reflect 13 the special interests of all of the expertise within that 14 region. 15 Then we supply them with a list of people fto,.,ii the 16 outside who are consultants, but they are only consultants.., 17 They cannot tell the region -- they can pass sortie judgment on 18 -whether the technical capability is there, but they cannot 19 pass on judgment as to vihether the region is asking for 20 a Cadillac, a Buick, or Chevrolet, because they have no 21 authority to do that. So a region can very well come 22 throughwith a proposal for $750,000 when it only needs one 23 for $250,000, not because they are trying to cheat anyone, 241 but because they would honestly like their patients wit lepofters, Inc.1 251 kidney disease to be.in a Cadillac rather than a Chevrolet. I And I think that this really puts renal programs into the @2 area of political interests rather than into the area of 3 technical interests where it should be. 4 And I might add that I think that this renal area 5 and the way in which it has been approached is a very good 6 example of the way in which the Review Committee has been 7 emasculated in terms of having an input into R,14P activities, 8 because all of this has gone on without any indication to 9 myself,, or as tar as I know, any other member of the 10 Review Committee in terms of how this thing would be organized 11 how things would go forward from here or not. 12 When you said, Ed, that these programwould-come 13 through and be passed on to you on the Review Committee 14 I can guarantee -you that you were looking straight at me 15 because the renal programs are being passed down to this 16 end of the table, the reason bein- that most people who do 17 not have nephrology expertise are not willin- to pass 18 judgment on these very expensive and hi-hiy technical things. I,> 19 And I can tell you that all that I am is a rubber stamp, and 20 if the other members of the committee will permit me, I will 21 tell you that I am not aboutto be the in-house nephrologist. 22 1 think that this is a-very poor way in which to approach 23 the role of the Review Committee in such a technical and 24 expensive field. Repoiters, Inc. 25 DR. HI,@,IAN: Lot md7 @espojid. There are several I points that you raised. First, my concern is that there be 21 Chevrolets for ail the patients throughout the country, 3 not Cp-dj.llacs. 4 SecondJ.y, there are other very technical projects 5 that are submitted for review by this committee, and to my 6 knowledge none of them are shunted to a particular specialist 7 or individual because of a particular area of expertise. 8 I am not sure that kidney should be treated q-,iiy differently fr-)-m 9 anything else in that respect. 10 Third, this could ail become a very r@iajor problem 11 if there v,,ere no guidelines to the regions as to the types 12 of activities that we are concerned with or feel that.would 13 be appropriate for the R,@IP dollars to go into. As lon- 14 as there is going to be any special handling of money for a 15 particular area that has to be some sort of guidelines so the 16 regions and the applicants can know what it is v@e are talking 17 about. This was one of the issues you all spent a little 18 time on earlier, about cormauiiication from this office to the 19 regions. 20 ,Vie are concerned -- and that's the topic on the 21 agenda called life plan -- with whether a region has developed 22 a plan whereby any patient who is identified ap@ being an 23 irreversible chronic rendal. disease and in impending 24 difficulties i.e., unable to manage his own .;eif, and Reporters, Inc. 25 needing assistance, should h-ave available to him access to care. This care i.rcludes iiiedic6-i ).ii@,@.-iiagement 0-ci well a-, the 2 adjuncts of hemodialysis and tratisp.LL4,ntation when it becomes 3 indicated. However, the costs of this, as Dr. Lewis pointed out, 4 are extremely high. The only way in which society 5 well, that's getting awfully grandiose -- but the only way 6 in which we can begin to meet these costs is for it to be 7 on a planned basis in which there are adequate facilities, but 8 not duplicative facilities, in which the most cost effective 9 method of treating the patient is the treatment of choice 10 whenver possible. 11 So that we are developing a guide that we hope will 12 become accepted by the Council and accepted by the regions 13 as a method of going about-it vihich will require that the 14 region have such a plan for care of their patients, that 15 the RI@ dollars would be used for selected portions of 16 helping them develop the resource, the pieces of this plan; 17 so that @vith the assumption that the reimbursement mechanisms 18 as they are developing in most areas will continue to 19 develop to support the cost:of the patient. This would 20 include an emphasis that early decision be made as to whether 21 the patient is or is not a candidate for transplantation, and 22 if not, whether the patient is a candidate for home hemo- ip 23 dialysis, and if not, whether a candidate for ambulatory conte.- 241 which i:s a lower cost hemodialysis, and as a last resort Repofters, inc. 251 institutional dialysis Nilien they reach that point, Dr. Scherlis. DR. SCHERLI,9: I admit to being a little further 3 confused than I was even earl.iort because if I am in the 4 position of being a member of the site visit group or being 5 a member of a local RAG and if I have before me several 6 projects to choose from.-- let ne,put myself in the position 7 of being a memb--r of RAG, with vicil defined goals and 8 objectives, and if I see that we have X number of projects, 9 one of which happens to be renal, and by the very nature 10 extremely expensive, and by the very nature givin- service 11 to a relatively small group of the population, I would have 12 to evaluate this service in teriyis of goals and objectives, 13 and' I would suggest to you that I would not support, lookii)fr 14 at a priority system, any renal project on a local RAG priorit7 15 basis if I am to iaoiz at the problem of the total delivery 16 of health care services. 17 It is not that I don't recognize the fact of its 18 importance, but I would suggest to -you that when a site 19 visit group goes out they will be faced with the same 20 quandary, namely, unless there are fairly firmly designated 21 funds that you wil I not see eight and a half million dollars 22 spent, but you will see only a small proportion of this 23 spent in terms of the total health needs, particularly as we 24 lool@ at the overall expo-ndod efforts of RMP. Repoiteis, Inc. 25 Now if I a3a alone in this point.of view then that I would be an interesting finding that I viouJ-d be led to believ@ 2 would not really exist. 3 I don't think the renBI. programs Y@,ould really 4 get the support or the priority rating unless they.are given tlii 5 point of view of specifically designated funds..,And I 6 would,like to have some reaction from other members of the Review Committee. It isn't that I an opposed to relial 7 8 projects, but you do jeopardize them by putting them in with 9 the general fund as far as- seeking levels of support. I 10 would suggest that those that receive several hundred 11 thousands of dollars now would be cut drastically and 12 that funds be used by core for what are higher priority items This could very well 13 in that region at this particular time. 14 be 'wrliat would happen, I predict. 15 DR . 111,N",IAN: This is the justification for the 16 continuance of a serni-riiarl-,ing of funds. 17 DR. SCI-MRLIS: I wanted to ask you what you mant' 18 by semi-separate. That was the best answer I ever heard to 19 an either/or response. Referring to question three, I 20 expected you to say yes, given that choice; but you said 21 semi-separate, and that confounded me further. 22 DR. HII@TMAN: This is the only program in which 23 there would be a partial earmarking of funds. Now the 24 word earmarking or separate fonds is a very dangerous I Repoitets, Inc. 25 phrase. If we start earmarking that a particular category for one reason or another should be handled by eight million 2 dollars out of 135 or such thinE,,, then the answers to 3 questions one and two are automatically going to start becoming 4 percentages and yes. And then the people that are interested 5 in other parts of the health care delivery system will be 6 seeking and. pushing to get an earmarking of funds and we 71 are back to purely categorical project review. 8 We are attempting to resist this as much as possible, 9 recognizing that the gap here in renal disease is an 10 unusually great one, recognizing that there has been unusual 11 interest in the legislative arm of government to see to it 12 that there are dollars going into this program and trying to 13 juggle between the tv.,o. That's why I say semi-'separate. 14 DR. SCHERLIS: Let's put this on the following 15 basis. lVe go to a region and they have asked for 2.9 16 million dollars, and We decide looking at the region that 17 their request of that funds includes $750,000 for renal, and 18 we feel that the needs in that region are so great in other 19 areas that the renal program really does not deserve support, 201 parti larly since we f,eel that the total request is out cu 21 of line. Therefore funding level is suggested which 22 specifically excludes renal. 23 Now what impact does your scriii-separato funding 24 have oh that decision, because the way that I would suggest Repottels, Inc. 25 we might go would be back to a national group which is Specifically chexged ivitli tile renal fundinf,), and at4L-eriipts to 2 got some distribution find sorao,;'41.(-iring of these facilities 3 on a lprge regional basis, and I mean the joining of several 4 states together. 5 .Could you first answer the first part of the 6 question, how viould you counter,-If-,t that? 7 DR. IiIh'ITAN: The first part, I cannot conceive of 8 enough funds becoming available for kidney that a $750,000 9 project from a particular region would stand up unless it vl,cr@ 10 a nine-ten interregional project, and the review Mechanism 11 for that has not been established. 12 DR. MAYER: Let's make it $300,000, $250,000. 13 DR. SCIMRLIS: I'll settle for that, $300,000. 14 Whatever it is vie put a red line through. 15 DR. IIAYER: The principle is absolutely critical. 16 DR. SCI@MRLIS: This is wi-iat happens iv on you go ou 17 to a region-- 18 M. MP@YER: This is what vie asked the Council, and 19 what we are getting back is mush. 20 DR. HIlRiLN: I have the 20 pages of Council minUtC3 21 here, the stenotype of them. 22 DR.ISCIIERLIS: iVe asked that they answer yes or no, 23 and we can't say semi-separate. 24 DR. ITAYER: Do you understand the question that Reportels, Inc. 25 he has asked? That is 8. very.important question lie has I asked, Dr. Hinnian. The question is what liapl@ns then by 2 semi-separate funding. Let's say we implement your-review 3 process, and it turns out that 'you staff feels that that's 4 a good renal program, but that review group has gone out ther3 .5 and said that's a good renal program but that's not.what they 6 ought to be doing in that region at this point in time. 7 Where are we? 8 DR. IIINIAAN: Somewhere along the line what the 9 region needs'has to be taken into consideration by either 10 you or by the Advisory Council, doesn't it? 11 DR. 14AYER: That's the question we are asking. 12 DR. WY,.I'I'E: May I make a comment? 13 DR. MAYER: iVell, let me just pursue it., because 14 I have the feeling that if in far-.t the answer to his question 15 is t'hat no further consideration is then given to that 16 renal project because in fact it is in fact iiithin the 17 total region's activities that's bein- considered, then 18 what Leonard has originally suggested is that you are not 19 going to get out of this review committee anything that 20, even comes close to approximating eight million dollars worth 21 of recommendations for kidney disease, you will be lucky 22 if you got a half a niii. Now that's my guess. Now that's 23 a fact -- I suspect it's a fact. I see a lot of nods 24 along, just as I save, them when Leonard inade the Repottefs, Inc. golng 25 statement, and hov,, are we going to deal with that? .1 DR. WHI-I'E: Seenis to me this is inconsistent with 2 what we are supposed to be doing the@3,o days. Vi'o are 3 determining, I thought, the quality of the reC,,ioii and its 4 ability to assess its own needs and the way in which it will 5 meet these needs, rather than our going out and sayingto 6 them these are your needs. And if we make that decision 7 about kidney problems then we are usurping what they presumably 8 should be doing. 9 DR. SCI-IERI,IS: In those regions when a renal project 10 gets to the local RAG it comes in differently, It really 11 doesn't compete for what else you are asking for. I know 12 that many RAGS approve renal projects because it is a, 13 different way of presenting it to RAG. It's a different 14 priority because -you are told don't.N,,,orry about this funding, 15 that's a separate vehicle, it really doesn't come out of the 16 total support that Nye will be given. It's a completely 17 different type of support that has been discussed. 18 Now if a region knows that it is asking for X 19 dollars and they are asking for it with a renal project standiig 20 side by side with what it feels are higher priority iteirs-- 21 DR. hiAYER: And if they know this Review Coirinittee 22 1 is going to look at it the same way. 23 DR. SCHERI,IS: We are changing the whole way in 24 which it is presented. It won It got out of the regions to Reportets, Inc. 25 get to us is what I a-,,ii suggesting. I may be wrong in niy gLlCSc3. 108 DR. Hil@,lilAii: At the present time, though the Rogi.onaL 2 Advisory Groups are not attempting to relate the magnitude 3 of the reDal pro-ram to the total needs of the region either. 4 I mean you are caught between the rock and the hard place 5 here, because it should be taken into consideration.. 6 I think Dr. Pahl vias just -- do you want to make 7 the comment that you made to Inc? 8 DR. PAHL: I don't think it will clarify it except 9 to say what the present procedure is, and one that we have 10 no alternative at the morm nt but to follow, is that Atio are 11 requesting both the re-ion and the site visitors review 12 committee to consider the kidney proposals as a separate 13 consideration from point of view of merit and invo vment in 14 regional activities and in fundng,and that these dual 15 recommendations, if there is a kidney proposal and 16 the regular regional medical program proposal, go to the 17 Council Nvhere in fact it has been up to this point also 18 handled in separate fashion. 19 We- are identifying -- coming back to the budget 20 matter, we are identifying funds to the tune of eight and a 21 half million out of this fiscal year, but there is not 22 a hard line item in the budget. And I think this is where 23 some of the semantic difficulties come in about sepzrate and 24 not separate. We have, been required to identify for Repoliefs, Inc. 25 what our level of spending is anticipated to be for kidney I projects, and we hope to identify kidney activities at 2 that level by the end of this fiscal year, The re is no itet,,i 3 within the Congressional appropriation which says that '%IC 4 will spend that much money for I-,idney. 5 DR. ?,IAYER: lViiat 'you have just said then, V@erb, 6 that it is separate-- 7 DR. PAHL: Yes. 8 DR. I,,IAIIER: And we should consider it separate? 9 DR. PAHL: We are requesting that it be CODqidered 10 separate and transmitted to the Council in that sense, 11 where they in fact up to this point, including t e last 12 Council meeting, are also looking at the kidney proposal 13 in any R?,,IP proposal as a separate issue, and at the last 1 4 Council meeting in fact have made separate motions relative 15 to the RTilP level of support and the kidney. 16 Now I am afraid I can't clarify further, and I 17 would sugfrese that if further discussion is to occur that 18 we have Dr. Margulies here, because I don't think Dr. Ifinnian 1 9 and I can say anything except over and over again what we 20 have been telling you. 21 DR. IIAYE.R: Vie went through this at the last 22 meeting and spent a iot of time on it, sent it up to Council 21, for a good reason, because this coii,,i,.iittee didn't know how to 241 act -- you know, they just didn't know how to deal v,,ith the Repotters, Inc. i 25 issue. flow, you know, if we are going to wait another three months to find out how to deal v,,ith the issue, fine, tell 2 us. But my assumption N,.,as we were going to got this 3 resolved at this meeting so we knew how to cleat with this. 4 And if you want us to deal with it separately then let's 5 talk about a review process that deals with it separately, 6 and I'm with Ed -- I think the review process you have 7 established doesn't provide me' %,ith what I need as a review 8 member. If we are going to deal viitli it together, then 9 we will deal 'With it together, end you have a limited 10 number of kidney proposals approved by this, but the review 11 process is adequate. And I have to have an answer to that 12 one way or other. 13 MISS HERR: And we have to me one step further, 14 too'. And that is if the regional program level is separate, 15 lest we have happen what we were discussing a, rhile a-o, 16 that they take the renal funds and use for another priority, 17 unless it is a separate priority. 18 DR. IIAYER: Ed. 19 DR. LEWIS: Just in answer to your initial comnient, 20 I really would not be so pretentious as to insult the other 21 members of this committee by suggestin- that renal projects CP AV& 22 or their scope are any more technical than any other project 23 or philosophically are different in any way. I think thet's 24 absurd, and I have never suggested that. But what I would F eporters, liic. 25 suggest is that both historically in terms of Congressional I hearings and in terms of the spirit of why rioney was initially 2 given to kidney disease, orid on the basis of there bein- 3 relatively few I)-3ople involved, and however you want to look at 41 all subjects being equal, I can tell you that the bud-ets of C> 5 these kidney programs are a hell of a lot more than I have 6 ever seen pass through this committee, that the thing is a 71 separate topic. And I cannot sit in judgment of every one 8 of these things, and I would doubt very much that Doctors 9 Merrill or Shriner sitting on the Advisory Council would 10 want to. And I really think that 'What -you.have done is 11 essentially emasculated what was not a bad,ray of reviewing 121 things in the interest of decentralization, the politics 13 of noncategorical approach, -and so forth. And right novi I 14 am left in a situation where I don't know how to consider Itidney 15 project, and boy, they are coming in in droves, I can tell you. 16 DR. SCJIERLIS:, Would the Chair entertain a notion? 171 DR. MAIRER: Vfell, Dr. Pahl was gettin- ready to 18 comment. 19 DR. PAHL: Well, in Dr. Margulies' absence I would 20 suggest that within R!,TPS concept ually we are treating kidney 21 as a separate activity from the review process and the funding 22 level in the manner in which we have tried to state. There 23 is a real separation at the staff level, at the review level, and 24 at the Council level. And if it is appropriate to have Repoiters, Inc. 25 staff reconsider its proposed review process I think that's 112 I most legitimate. 2 The best t,,dvice I cttn give you is that we are 3 requesting that you consider the kidney proposals separately 4 because we are into this semi-earmarlzing of funds and this 5 does require us to look at it in a separate fashion. So 6 the conceptual framework is, I think, quite clear, and we 7 must ask you for specific advice on the kidney proposals. 8 I think also it is fair again to have you look at, 9 consider, and advise us as to whether you think we now have an 10 appropriate process to do this or not. But I don't want to 11 leave you in doubt as to how we are reviewing kidney-- 12 DR. SCHI-:RLIS: I ju,,3t want to a-ck one question. 13 What do we do when we go into a region and they say,part of 14, our budget is a renal project. Do we say we don't want to 15 look at it because that ha,-z a separate mechanism, or do you 1 6 want us to say vie recommend zero fundin,,,, in which case what 17 do you do in R@-U)S? This is the logistical bind that we are 18 in. I don't think I had an answer to that. I don't mean 19 to be difficult, but this is exactly what we fare when vie go 20 into a region now. What do you reconuticiid we do, look at it 21 or not look at it, and what level do we look at it? 22 DR. HINMAN: We recommend you look at it as you 23 look at the rest of the program, but we hope to be able to 24 supply you with specific questions, concerns or comments from RC.,Potteis, Inc. 25 their review to guide you in looking at it. li3 There were two site visits held during the Deceinb,-r 21 Cycle Of site 'visits iD Y,,Iiicti tlvre were specific questions' 3 posed that needed to be answered so that recommendations 4 could come to you today. We hope to be able to provide this 5 type of support for,the site visit teams. 6 DR. MAYER: Let me try to get at the same question ii 7 different way. As I listened to your original report, 8 Dr. Hinman, I implied that the answer to question three, which 9 was whether renal programs funded by the re-ions will come 10 out of their toal budget or out of a separate budget, my 11 initial reaction was to write down comes out of their total 12 budget; end when I got to question four from your commentL-, 13@ I implied -- whether renal programs should be considered outside .14 the total regional activity or not -- I wrote down not 15 outside. 16 Now what I heard Dr. Pahl say to me suggests that 17 what I answer to number three is it comes out of a separate 18 budget, not the total budget, and what I have also implied 19 is that it comes outside the activities, 20 Now we have just literally got to have an answer 21 to those questions or we can't function in the renal area in 22 the manner in which I think we have an obligation to function, 23 and that's why we sent the questions up to Council four 24 months are. And I can't be more explicit -- I'm not trying Repotters, Inc. 25 to be obstinate, I'm just trying to -- tell me what to do, and 114 by George, I'll go ahead and do it, but don It give me soriiethitil., 2 that I can't do or I object strenuously. 3 DR. ITESS: I would like to ask for perhaps some 4 historical clarification at least as to why we are in this 5 dilemma with regard to renal disease. How come this.is 6 treated in such a special way as opposed to coronary care 7 units or cancer treatment Centers or any other kind of 8 categorical type activity? Is it a matter of political 9 wisdom that some people in Congress or somewhere else have 10 a real thing about renal disease programs and this is the 11 price that we pay in order to get favorable activity on other 12 funding for the Regional Medical Programs as a whole,-or is 13 this something at the Council level, or where did @his all 14 come from? 15 1 think if we know the reason why we are at this 16 point in history it may be able to help us see our way out 17 of the current dilemma. 18 DR. PAHL-. Let me preface my going off t e record 19 by saying I will give you the best ansNver I am capable of. 20 Now I would like to go off the record. 21 (Discussion off the record.) 22 DR. hiPYER: If that is the case I need to know then 23 what is the answer to question three and question four that 24 this committee asked of the Council. ePorters, Inc. 25 DR, PAHL: Lot me try once again, The Council I provides a budget to the region which c,,,pecif ics whether or 2 not the I,.idney activity has been approved in ivliole or III 3 part and specifies the dollar level for the approved portion 4 of the requested kidney activity. The applicant receives 5 one grant award statement together with the information 6 about the specifications. So trying to get away from the 7 semantics, there is one budget figure for the region which 8 is shown on all records, but which involves a number of 9 dollars specifically earmarked for whatever ha-s been approved 10 by the Council for the kidney activity, In that sense 11 the region has one single total budget of which a portion 12 is earmarked by the Council. 13 From our point of view one grant award is given 14 out of R!,I@o funds, but we identify for the office of the 15 administrator and other units of govornirtent that a certain 16 number of these dollars are for kidney activities, the 17 sum total of which we anticipate will approximate eight 18 and a half million by the end of fiscal 172. 19 I hope that identifies total budget and separate 20 budget. 21 DR. MAYER: Now question four. 22 DR. PPML: Well, lot me first try to answer 23 point four, and perhaps Dr. Ilinman can read you an appropriate 24 statement from Council, epottefs, Inc. 25 We in P,!,Sl')S believe that the kidney activities from I a program point of View Should be revic@ved at all, levels 2 v,,itliin the total context of tho Regional @'ledical Program for, 3 that area. So forgetting fundin%,,, asidel-we are interested 4 in having our own staff, site visitors, review committee,. 5 and Council consider Nihether the program in kidney activity 6 proposed by the region makes sense for N@that the region is 7 proposing to do, and whether it has the capability to carry 8 out its total program, including its kidney activity. 9 We are not trying to keep it separate from a 10 conceptual or progrwi-matic sense. Yet we Trust identify at all 11 stages that it is separate up to and including the funding in 12 the manner in 'which I have tried to explain to you. 13 DR. I.IAYER: But that's where we are on the horns of 14 a dilerrana, because you dan't do,ttiat. In other x@:ords, 15 if you go into a region and you tp-ke it within the total 16 context -- you know, what I indicate(I'and Ed has suggested or 17 Leonard suggested might occur,, will be that there will 18 really be that there will really be nonapproval of kidney 19 project after kidney project.after kidney project, and therefore 20 the political decision that has been made -- and I am not 21 saying that that was an inappropriate decision, you know -- is 22 not going to be adhered to. So you can't unlink program 23 and.dollars, and anybody ivho trios to unlink them is going to 24 end up with chaos. And that's @,ibere this co,"unittee is, and Repoiters, Inc. 25 vie have to know whether you %itant us to review that a part 117 I of the total prograia, and includin- their funding, or whether 2 you do not. And if 'you do, -you know, then are fire going to take 3 one approa--h to it, and if you do not then there's another 4 approach to take to it, and it's really as simple as that. 5 It's not that complicated a question. 6 DR. PAHL: Well, I v@,,ouid have to state that since 7 we have spent several meetings and seemed ail to be acting in 8 good faith and toward the interest that it would seem to be 9 that complex. We have requirements on us which we must 10 discharge which are coi-apiicated by the history, the political 11 coi)text,, and the funding. And -yet we are attemptin- within 12 the concept of a Regional @ledical- Pro-ram to look at the 13 capability of their carrying'OLlt what they propose tp do 141 and the nianner in which they propose to. Lltiiize their own 15 stpff and funds. And it is a dilerrdnan, it's not the only one 16 we have. I really can't clarify what it is further that 17 we are attempting to do. I recognize the dilemma. I do not 18 have the answer for you. -I believe that unless Dr. Hinmati has 191 it from Council,, which is- a@tr,-lnscript which we will be 201 happy to place before you in xerox form, lot you read and discuss 21 1 further, or read it to you, which is someviliat lengthy, or have AM 22 Dr. Maxgulies give you the cleprcut answer, I cannot be of 23 further assistance in resol viii,-, the dileiiina for you. 241 DR. !tgiYER: Then we have to rc@soi've it ourselves. Is F-e at @epoiteis, Inc. 25! that what' you are saying? We will be glad to do that because, I you know, we have got to have settle resolution, If Council 2 can't do it and staff can't do it, then we have to do it 3 ourselves. And we are glad to do that, I suspect. 4 DR. PAHL: Vloll, let me throw it open to staff, 5 because I really feel I have failed the Review Co,-,tiiiittee in 6 trying to do something which which Dr. Marg@lies apparently 7 to this date has not also been able to do either. Is there 8 anyone in the room that f eels that they can state better than 9 I what we are attempting to accomplish or say it in such 10 terms that we can get off the tiorii, because we all are trying 11 to act in good faith, but I am unable to do more than what 12 I,have just attempted. So I would have to say if it comes 13 to one or the other acting, you art and v@ will respond. 14 I would suggest before the committee takes the 15 action that you permit Dr. lliiiinan to read what lie thinks are 16 appropriate sections which I think we can condense from t e 17 Council transcript, because part of our difficulty is that 18 we are intermediaries and it wasn't that much clearer at 19 Council meeting. So if you would like to have it perhaps it 20 would be helpful. 21 DR. HINNIA',Ii: After the lengthy discussion about 22 kidney at Council Dr. Margulies summarized what he took to be 23 their sense of discussion, and they passed it. 24 "It is the sense of the Council that you wish to Repotteis, lric. 251 continue to review on the basis. of the merit of the proposal, 119 I that you are not in the position to determine year by yeq,)- 2 budgetary allocations; that you would like to be in a 3 position, hoyiover, to'criti.cize the budgetary decisions which 4 are made and have some accounting of how those budgetary 5 decisions were made; and what 'you mean by regi.onalization of 6 being associated with rep,,iodalization of kidney activities, tha,-- 7 this can be either through an R@,IP or through a section 910, 8 but that it should be designed in such a way that it 9 services the broadest possible public interest." 10 M. MAYER: That doesn't deal with the issue. 11 M. HIIIMA14: I have a practical suggestion for 12 today, which is what you were getting to, Dr. Mayer. It 'would 13 seem -- and the thing that will allow., something to be 14 transmitted to Council for them to have the dilemma would be 15 a three level thing. one, to approve or disapprove the 16 kidney projects that are in the particular regions you are 17 reviewing today, to establish a dollar level for the region 18 without the kidney project in it, and to suggest a dollar level 19 for the kidney keepin- the total regional needs in mind. 20 Is that clear? Or possible, I should say. 21 DR. ?,!AYER Tell, without having the individual ip 22 proposals before us you know, I was very fortunate in the 23 one I had which had a kidney proposal bocause I wasn't 241 presented with the dileiiiiia because it did have ad hoc kidney Repoiteis, Inc. 25 group report,on it, and they voted a-ainst it, ctil three parts of it, and so it solved my problem. I didn't have to fnxe 2 the issue. But I suspect there may be one that is meritorious, 3 and then I don't know with the ground rules we now have how I 4 am going to make a decision relative to that, and I guess we 5 just have to wait until we get to that or we establish a 6 principle now in terms of how we are going to deal with it, 7 because it really relates to your proposed review process, 8 because depending upon the answer to that question I either 9 accept or reject, -you know, the kind of assistance you are 10 going to try to provide us in the review process. 11 Yes, Ed. 12 DR. LI,;WIS: I would just like to add to the chaos 13 that exists by saying that these proposals by virtue of the 14 fact that the signals keep changing are not being reviewed 16 in a uniform way; ergo, I was on the site visit team to 16 Florida, the Florida program was reviewed by me, the bud-et 17 was reviewed on lilonday here in Washington with the people 18 from Florida and with'the prop.Le from the kidney program, by 19 myself, and it has DOW passed up to the review committee. 20 on the other hand, other renal protyro,7ns have come other 21 ways. Some have come straight up in the manner in which qp 22 Dr. Hinman is suggesting it should be done in the future, 23 others have come through the ad hoc review panel. And I 24 think that this is really highly unfair to-poopic who are -et Rcpot teis, Inc. 25 applying, and I don't know what the answer to this is, because 121 I there is a def inite need, the money is there, and we have to 2 do something. But I think that this must change. 3 DR. @IAYER: lVhat is the sense of the committee in 4 terms of how we want to approach this? Do do want to Wait 5 until they get to the test case, or do you want to arrive at 6 some other kind of approach? 7 DR. SCIIERLIS: I would suggest that Aye might best 8 defer all renal projects until we can consider them in a uniform 9 way, because I am sure that practically every renal proj ect 10 which we present to this committee will have cleared RAG 11 on a totally different priority system. And I'm not opposed 12 to renal projects by any means, Having two kidneys myself, 13 I cherish them. But I think that on a priority basis lool,,,i.iig 14 at the overall needs of a health region, I think there are other 15 things that a RAG might act on, and unless we have uniform 16 instructions to RAGS and to this Review Committee and to al 17 members of site visits we are going to be measuring renal 18 programs on a changing yardstick, and I don't think this is 19 fair to those that are turned down for reasons outside of 20 consideration that we impose on other regions, 21 I know your confusion, and that is you were not 22 given any clarification at Council. That's quite apparent 23 from what has been said. But I think in all fairness to 24 having to answer yes or no to regions which have spent Repotteis, Inc. 25 literall.y years evolving well coordinated projects, I don't to another# e region on can co see low we in fairnesf her not- a progrwnt thc3 ot having could 2 One then? suggestion viliat is -your 1AAYElt. DP. # ti 3 ne-Y activity of the xid to other PIrts 4- we then mOv() on head on when NYO are ftwed at this that -we 'Will get 5 and asSum ting. 6 With realit'Y tes points that I two other Dp N: There v.,ere 7 to review related bringto 'Your attention un 8 wanted to 9 pie chan isms - 1 progr@@ one is that there are a number of federa 10 ding in stage re,, US aspects of fun involved in vario 11 that are cooperation and and to date the -Leve 1 of 12 disease# its highest. coordination betN@,een them has not boon at 13 ificall'Yp that there in certain kOY a3700--st three s@c 14 feel that elnent @ to .ne cc n al protocol or so tral agre 15 should be a ccl)tr t hat Ot f these areas goes on so 16 how funding and support 0 1 o providers ation will be available t 17 some Point in time inform to (10 for patients. hat Will be the best thing lin 18 9,9 t o w @re antil,ytnphocyto globu The three areas 19 ,,,Ssity, and ion, IILA t'YPing and its value and 2 0 preparat lysic,; and transplantation. information of both dia VP 21 registry h the . itiated discussions Wit To this end 'we have In of 22 t with SOr-110 sort 23 ,ellcics invo@Ved to attempt to co,, ou I one beino antilylAphocYtc 19 the most cruci,L 24 conuixon -PrOtOco s is of value t.(Joes turn Out that thi Fedetat Repot leis, Inc if i 25 I,btiliri, becaus 123 I in transplantation patients the necessity for the Food and 2 Drug Administration to license it so that the re can be 3 commercial production becomes an overriding issue at some point 4 in time. So we are trying to get the FDA, three Institutes 5 from NIH, the Division of Biolor,,ical Sciences, Arthritis 6 and ?,','etaboli.c Diseases, and Allergy and Infectious Diseases, 7 the V.A., and our group together, and possibly including Soi.-O (f 8 the Department of Defense activities, because we are all 9 involved at some level in fundinfr So we hope that from this 10 something can come forward that will be of assistance 11 in the field of kidney diseasei.. 12 The second point is in light of this, and because 1 3 of some of the other controversy and probiertis in tile area, 14 it is recommended that any project that requests funds to 15 produce antilymphoc-yte globulin, that review or approval 16 of this be deferred until there is a coordinated strategy. 17 This recommendation was accepted by Dr. Mar-Lil.ies. 18 DR. ITAYER: Is that here for our information or for 19 our-- 20 DR. 111@%fliN: For -your information. 21 DR. MAYER: Ali right. Do you want to comiont, Ed, 22 anyway? 23 DR. IX-WIS: yest I would like to comment anyway 24 that I think it's unfortunate that one of the few things Reporteis, Inc. 25 that RIIPS can do and that is fund at least local use of i24 .1 antilymphocyte globulin, which I 'would put out to you is 2 offeective, because I think a panel of experts v-iili argue 3 from now til the co@vs come home about %,,,hether it is or not, 4 but at least it is as effective as coronary ... in the care 5 of the patient with the MI, and I think this is the one area 6 where people could have gotten some help and now it's an 7 area that has been cut off. And I would also put to 'you 8 that I personally believe that FDA will never, never pass 9 antil-ymphoc te globulin for interstate commerce. @Tever, 'Y I0 DR. NIAYER: Any comments from staff about that? 11 Okay, we have got a prediction on the record then. 12 Dr. Hinman, any other iteirLs? 13 DR. HINIMAN: That's enough headaches for,,today. 14 DR. IIAYER: All right, I would like to turn now to 15 report from Mrs. Kyttie. She has a couple of issues she needs 16 to point out to you. Lorraine. 17 MRS. hYTTLE,: Should some of the items that 18 Dr. Margulies discussed earlier today require a movement of 19 the Council -- and I would ask you to turn to the calendar in 20 -your books if we were to move Cou.ndil' f roni ti ay 1) ac kto 21 April, and therefore move committee back from April to 10 2 2 ?,larch, would the dates-- 23 DR. MAYER: The other way around. 24 DR* PAIIL: Move coitiniittee from April to @lay. Repoilefs, ltic. 25 MRS. IVTYTTLE: Right, Excuse me, I'm going in the Y-irong direction. Iliii soi@r-y. Would the dates asking YOU 2 still to keep April 12 and 13 lo-[,md for the standin,-, )nEietii)g, 3 would the dates of 10th and lith of l@@lay be agreeable for a 4 meeting that could be put on the books, and when the thing 5 finalizes Ni@,e can say whether Nve will be meeting in April 6 or May? 7 DR. MAYER: Not for me, for one. 8 14RS. KYTTLE,: All right. 9 DR. MAYER: I have seen three. Any others? Four. 10 MRS. YYTTIE: To move it up or back in that il,,eek, I 1 Would that help? 12 DR. MAYER: 8th or 9th, 12th or 13th. No. No. 13 10th and lith. 14 IIISS KERR: There is a regional conference that 15 has been long scheduled. 1 6 ims. KYTTLP,: The N,@liole week. May 8 or 9, or 17 9 or 10, some time in that week of the 8th through the 12tli 18 of May, two days. 19 DR. MAYER: How many cannot be there on 8 or 9? 201 (Show of hands.) 21 DR. MAYER: 9 or 10? 22 (Shov., of hands.) 23 DR. NTAYER: 10 or II? 24 Repo,,tcfs, Inc. (1,3how of hands.) 25 I,UTS . KYTTLE: At the risk of pusliin,,, it into Council, is the week the 15tli through the L9th better? 2 DR. it is not for me since vye have 3 graduation and that's one thing a dean doesn't miss. 4 IIRS. KYTTLE: The latter part of the viel@ of. the 5 4th or 5th? And that will put staff on its ear. 6 DR. I.IAYER: That's better. All right, how many can't 7 be here the 4tli or 5tli? There's one. Just one. 8 @MS . KYTTLE@ now thini@ing of your travel, it is 9 sometimes hard to get out of here on a Friday, which is the 9t!l, 10 is the 3rd and 4th-- DR. MAYER: Ilow many can't be here the 3rd or 4tli? 12 DR. PERRY-. 3rd only. 13 DR. MAYER: So that's one and a half. 14 I.TS. KYTTLE: 4th and 5th seems the best. Dr. Paill, 15 do -you think maybe it might wind up as a one day Friday 16 is darned hard-- 17 DR. PAIIL: I think we have to consider a. two day 1 8 meeting, and please understand this is still predicated on 19 our receiving instructions as to whether we are going to 20 be I)ringin- you additional grant applications in the area healt@. 21 education center, and that one is trying to be decided by 22 the office of the Administrator. It may go contract roLite'. 23 in which case Y;e may not be compiled to hold the meeting 24 later than the currently scheduled one. So we are r@l@iDg Reporteis, Inc. 25 really that 'you consider a two day meeting in ?.lay rp,,ther than a tWo day meeting in April, but )Holding all dates open for a few days until we can try to come back end cancel one 3 of the two proposed meetings. DR. IIAIRER: Oka.,y, then J.et's tentatively hold on 5 to relay 4, 5, because even though l@riday travel is abominable 6 out of here, if you have got a inonth's noticeor tv,,o irionths' 7 notice you are in pretty good shape. 8 All right, other items. 9 IIRS. Y.YTTLX,: The green document that we pa@sed 10 out, we have because we thought it might help you with some 11 of the deliberations that we were wrestling with this 12 morning. 13 The other document that I am passing out, is showing 14 you how through the last review cycle your ratings 15 placed the region. The box in the middle shoxs the specific 16 ratings by the committee, and the items to the right show 17 the staff anniversary review ponells conclusions that care 18 out of the last review cycle as well. 19 DR. MAYER: Try me again, 20 tiRS. KYTTLE: The box in the middle represents 211 I/ the ratings and therefore the placement of the region in 22 an A. B, or C category on those regions that were site 23 visited and specifically rev@ewed by committee last time. 24 That's'the box in the middle, The box to'the right are the Repoitets, Inc. 25 rating.s-@ that came out of the staff anniversary reviciv panel, I and you remember last time our procedures, we N,@ere just 2 beginning, and those regions that were anniversaries within 3 the triennium just went through, they are coming to you this 4 time as timely information rather than post information. But 5 this is how the regions that were anniversary applications on tl.e. 6 right fell out via staff anniversary review panells rating. 7 That's how they fell into A, B and C. And, of course, the 8 information to the left is as it says, the July, August cycle. 9 DR. tlAYER: And the adjusted raw, what-- 10 MRS. KYTTLE: Well; the 'July, August cycle was the 11 experimental, and for openers some of these had to require 12 adjustments, because when October, NoVeTab,-,r cycle came out you 13 could see the differences between the setti.ed ratidqand the 14 for opener ratings, and that's the difference between raw 15 and adjusted. 16 IIR. PETERSON: What we found, Bill, was as a result 17 of your initial trial the average rating in the July cycle 18 was around 260. When we looked at your next P4vornge it 19 was, if I reinem ber the figures correctly, 301, and the first I - 20 stclf f panel was 303 p which was, given a 500 scale, seemed about 21 right. So vie took an adjusted mean and multiplied your 22 earlier scores to make them roughly equivalent to the two 23 succeeding actions which tended to Cluster the mean right at 24 about 30'0. Reporteis, Inc. I 251 ln'RS KYTTLE- This places 27 regions, end no.xt time we will come to you with the chai,t that N,,,ill add 12 to it from 2 this. 3 DR. I.IftYER: All right. other cor,.,nents? You were 4 going to comment on some discrepancies betvlecn Council and-- 5 IM5. KYTTLE: Yes, from the last October, Novemb(3r- 6 review cycle the recommendations of committee on Arkansas 7 were accepted by Council, the recommendations on Arizona, 8 and Colorado, Wyoming were accepted; the recommendations on 9 Connecticut wore not accepted, and when we finish I will have 10 something before you on that. Iowa was accepted, Indiana 11 was accepted; and Ohio Valley had an adjustment, a modification, 12 Virginia was accepted. 13 The items going ta Council from the staff anniversary 14 revic w panel generally were accepted with t%vo slight 15 modifications; Tennessee Mid-Soutti"had a slight modification 16 and hTew York Metro had a slight modification. 17 The three standing kidney proposals that came to 'you 18 last time were accepted by Council. Georgia and Rochester 19 came out to be negotiated with budgets, and those budgets 20 have been negotiated. 21 In your book under the pink tab at the very back 22 under other business are three documents, T@vo of them concern 23 Connecticut, and one concerns Ohio Valley. And at the risk 24 of working from the back up, the difference in Ohio Valley Fcoe,,,l Repoiters, Inc. 25 turned on Cotincills disapproval of the kidney project within I that proposal, and their rationale is there. the modification of the Connecti 21 The rationale on cut 3 recommendation is more extensive. Yourecall that committee 4 came out with several suggestions, and there are two responses 5 there, one to the decision that the Council made on the 6 recommendation itself, and the second is Councills response 7 to several of the suggestions made by the committee. These 8 have not gotten to you before. Yo6 see them in -your book 9 for the first time. And, Dr. Mayer, if-you would rather take 10 a minute to read it or take it up again tomorrow, whichever 11 you wish. 12 DR. MAYER: No, I think it is very important that 13 this reIview committee do understand where it is runninrr 14 counter to the Aislles of Council because it is helpful to us, 15 because- in a sense that's one way in which policy is established, 16 And I would simply suggest that we take this information 17 and review it and think about it, and set aside a little bit 18 of time tomorrow to discuss it rather then to try to do it 19 now. 20 MRS. KYTTLE: Attached to your agenda is t 21 statement about the confidentiality of the meeting and the 22 conflict of interest. 23 DR. @FAYER: And I think I would only add to the 24 confidentiality a mqre even explicit feeling that the review e-Fedeial Repotters, Inc. 25 cycle rating sheet which you have is handled with extreme c,-,re, I 1 becp-.use if in fact tlic-i.,e are going,, to be dollars attached 2 to those, as was suggested at the outset of this meeting, 3 it tal@es on even more importance that tti---y be handled with 4 exquisite and extra care. 5 IMS . ICY TTLE Dr. Pahl, would you want to mention 6 anything about the discussion of the rating and the criteria 7 with the steering committee? 8 DR. PAILT,: lVell, the only point is that as we had 9 informed -you earlier,, we would not fully implement the 10 rating and review criteria until the steering corrniittee 11 representing the coordinators had had an opportunity to 12 conbrent upon this to us, and over the time period since vie 13 last met vie have again informed the steering com nittee of our 14 interest in formalizing this as a part of our total review 15 process and Tried for comments again. And then we met with 16 them in Chica,-,o the first week in Decembcr and' they 17 uniformly endorsed that we proceed with it, and I believe, Pete, 18 a communication b.@- gone out now. 19 @M. PETERSON: It is in the process of goiti.- out 20 Dow. The actual letters to the 56 coordinators are bein-, 21 put in the mail now. 22 DR. PAIIL: but it is clearly understood by the 23 steering committee, and thus all the coordinators, that the 24 reviovi criteria and the ratings, v,,eights,'etc., that you hove I Reportcts, Inc. 25 before you are now part of the R.',,@IPS revi-ew process, 132 1 1 should. really say that this endorseiqont by the 2 steering committee was riot given in a FrrUdging way. Many 3 of them felt it was a marked improvement in communication 4 in the sense that they now for the first time did understand 5 some of the points on which they would be reviewed, and there 6 was a common basis that would be applied across all regi-ons. 7 So there was some degree of enthusiasm voiced at least 8 by the steering committee riembcrs that Nye have this, and let's 9 stabilize on it and move ahead, subject to change after a 10 year or more of experience, But we have stabilized OD what 11 you have before you. 12 Dlil. MAYER: Could I just ask one question while we 13 are on it? The figures that are there on the R.MPS ratin- 14 sheet which you provided us, Lorraine and I am i)m,, 15 asking this because it is quite clear I'm talking about 16 the single sheet that had the box -- I need to know if those 17 figures are the sum-of the weighted numbers or are they 18 represented as overall assessment numbers only? 19 MRS. KYTTLE: They are the ran-e of the weighted 20 total score given by reviewers. Your middle block, for 21 instance, Arkansas and Iowa, ranging fro-.i 339 to 34i, those 22 then represent the scores of all of the reviewers with the 23 weightings taken into consideration, divided by the 24 number of reviewers, and one of those tttaclies to Arkansas and -Fe Reporters, Inc. 25 one attaches to Iowa. i33 Does that answer your question? 2 DR. ?&AYER: yes, I guess it does. It causes me some problems. How have -you handled those in which someone 3 4 has failed to put a number down in one of those little 5 blocks? 6, MRS. KYTTLE: Frank. 7 14R. ICHNIOlrbKI: We treated it as a blank and took 8 it out of the calculation. 9 DR. IIAYER: That becomes important because what 10 we were doing, you recall, was circling those ones in which 11 we had some discomfiture with. How are -you handling those? 12 @M. ICHNIOIIISKI: Ife counted just as you scored, 13 even with the circles. 14 DR. MAYER: All right, because that has some 15 implications about ",hether I wn going to circle or leave 16 it blank from now on. 17 NM. ICHNIOWSKI: The number of circled items last 18 time comprised only about 15 percent of all the scores, vihich 19 didn't have a major effect. lye tested taking them out and 20 it didn't change it. 21 DR. litAYER: Is everyone clear on those questions? 22 All right, why don't we break for lunch, try to 23 be back by 1:30, and Nye will start in on the individual 24 projects. It would be my intent to go through them roughly f@lF,O*et,,l Repotteis, Inc. 25 as they are outlined on the sliect. 1;5 4 (Whereupon, at 12:50 p.m., the meetiii- recessed, 2 to reconvene at 1:30 p.m.) 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 -20' 21 22 23, 24 RCPoftefs, Inc. 25 135 AFTFRNOO.N SL@ISSION 2 (J-:30 3 DR I(,AYE R: thought vie might before we staTted 4 in, in that Harold is here fortunately with us, We might 5 just comment briefly on the kidney issue that we were 6 discussing with him presenter think he understands the kind 7 of dilemma which we are faced with fairly clearly, And I 8 guess the feeling was in this morning's discussion, Harold, 9 that the answers we got back frora Council and as staff t en 10 interested it left us the same place we were four months 11 ago vihen we sent the request up to Council for clarification. 12 We &,re still on the horns of the same dilemma we had 13 previously. 14 DR. MARGULIES: Well, I think that the best way to 15 handle the kidney review and funding activities is to keep 16 them separate from the @f,@ionai Medical program application 17 itself. I think it is quite clear that this has caused a 18 great ainount of confusion. So what we will do is allow 19 regions to submit requests for support for kidney activity. 20 We will continue to identify a separate amount of funding 21 as we have indicated we would for this purpose. 0 22 We will ask the review co,-nmittee,with the assistance c 23 outside technical review on each one of the kidney px'ojeCtS, 241 to review the proposal and to make its recorb@ndations) -Fe e,,l Reportets, Inc. 25 and Ave will keep that sepa.-rate from the review of the This will mean that for each I Regional Medical Program 2 renal project there will be outside consultation -- that is 3 consultation outside of that region, to make s ure that there 4 is adequate technical review, and the committee will receive 5 the results of that kind of technical assessment as well as', 6 of course, the staff assessment of it. 7 DR. IMSS: Any given renal project will be used 8 specifically for that then. 9 DR. IIARGULIES: That's right. It will be regarded 10 as a separate category. We will continue in this process to 11 try to build it around a national network of completely 12 adequate facilities for dialysis end transplant and have 13 that kind of a design in mind, as we have had for well over 14 a year. 15 DR. SCHERLIS: And when we go to a region as a 16 member of a site review committee we should not make any 17 judgment or recommendations on that project, is that right? 18 DR. @LKRGIJLIES: IIL'eep the kidney project separate. 19 DR. SCHERLIS: In other words, vpe make no 20 evaluation of that project. 21 DR. @IAYER: Well, I su,.3pect that the evaluation 22 ought to at least include now that Regional A6visory Group IC 23 and others them.-,elves look upon that end Ahat are that stqff 241 capabilities of administration. I think those kinds of issuc@ Fe eai Re Poftefs, Inc. 25 are probably appropriate. 137 I DR. SCIIEPLIS: A,-, f z,. rfunding we look on that 2 entirely separate, don't make any rocoirmie ndatiods on the 3 funding of the renal project? 4 DR. MARGULIES: Not as a part of the site visit 5 or the RIIP. The kidney activity would be considered. 6 separately. If there is a request for a kidney proposal at 7 the time that the RI.IP is being reviewed end if the review is 8 carried out at that time then we will have people to look at 9 that particular activity separate from the rest, although 10 as Bil.L has indicated, %Yhere there is obvious need to look 11 at the two together that should be done. 12 DR. PERRY: This is probably the best part of 13 all. If you are fortunate onour@li to have Ed Lowis,y;ith 14 you on the review committee -you can iook at it in relation 15 to the total, but you can' really look at its merits also at 16 that point. 17 MISS KERR: Then these kidney funds are earmarked 18 and are not interchangeable with the other funding or the 19 other progreun? 20 DR. MARGULIES: Thalis the way we will administer 21 them, yes. 22 DR. SCI.TU@RLI,@3: Has that decision been made on 23 the basis of the discussion we had earlier this morning 24 or is that the decision reached at Council? a, Reporlefs, Inc, 25 DR. MARGULIES: That's pretty much the way it was i38 understood prior to the meeting of the Council and after 2 the meeting of the Council. As I have tried to say on many 3 occasions, there is just no question about the fact that the 4 kidney activity is categorical and that it in fact addresses 5 only a part of the kidney problem, in stage kidney disease,, 6 and it's a purely categorical activity which needs to be 7 kept separate from the broader ranges of R'l"lp activity, And 8 since it has been difficult to try to took at them in a commoi 9 context I think it is quite clear that we should apply the 10 separate categorical review process. No'%, the only difference between this and what we 12 have done in the past is that we are attempting, and we hope 13 to get more effective in the course of time, to do this in 14 such a Nyay that we do over time cover the nation's needs 15 with centers, so .,,e are going to be looking at it here in 16 terms of locations for-geographical access. 17 DR. THURMAN: I think one thing that makes that 18 exceedingly difficult to take a very specific exanxple, 19 the Greater Delaware Valley.-- if you had t,,r,,o hands and two 20 feet on which to count on the site visit at Delaware Valley, 211 it iv@- obvious that they had no pl.aii that really went to 22 regionalization of kidney disease. They are talking about 23 opening more when they don't have enough to run one. It's 24 very hard emotionally, mentally, fingers,-toes, or any other Reporteis, Inc. 25 way to sit there and say these guys really know what they arc L;j i) talking about in any catef,-ory if they are that blind in kidney -2 disease. That's the real problera, and I thini@ that's the 3 one that precipitated most of the discussion here this 4 morning. You cannot take any categorical. disease and remove 5 it from the rationale of what RMP really stands for, because 6 that's where it started. That's where even though the 7 category ha.-, changed meen'even though the mission has 8 changed, it's still very difficult to look at a group of 9 people who are' going to be spending a dollar" and not say 10 can they really do it even though this process would be I I categorical. 12 To give you a numbers game, they don't have a 13 hundred transplants a -year and yet they are talking about 14 opening five centers. Well, tliatts just totally unrealistic, 15 and it certainly puts a bias in the reviewer's mind about 16 the rest of the program if they are not working to-other C2 17 well enough to do that. 18 DR. I.IARGULIES: I think your point is mrfectly 19 valid. But one of the things we would anticipate would be 20 looked at iD the process of carrying out technical review of 21 a kidney proiposa.L is whethe r there is evidence of a capacity 22 to concentrate facilities andto produce a regionalization 23 of the program, and if it's evident either directly or 24 indirectly that that's not the co-se then this would not c a .,I Repotters, Inc, 25 fit project for support. lliu I think you will find if you keep them separate in thi 2 review process that it will be possible at the time that 3 the review committee meets to raise the kind of question YOLI 4 just raised more comfortably than if you tired to intertnvine 5 them at the time of the review process. IVe are cati[rht a little 6, bit one way or the other. 7 DR. TIIURMAN: I would just argue the reverse. When 8 you are sitting there tail,.ing to the guy who is doing all 9 the rest of it, it's very difficult N@rlien he says "I can't 10 count potatoes, but I can count oranges." You wonder how the 11 heJLI he's doing it. And th at's really what it amounts to. 12 And that automatically puts a degree of bias in the rest of 13 your evaluation if we are doing to look at it that,,%,v,-iy and 14 yet still think of it entirely separately. 15 DR . MAYI,',R: I guess, Bj.IJ., where I am, is that 1 16 am far more comfortable with a decision having been trade, 17 that if those recommendations conie from that expert panel 18 and I have been into that region and.looked at other issues 19 and look at what that region is doing about refrionalization 20 in other issues, and that review panel on kidney disease comes 21 in, one of the key things that I ain going to ask as a review 22 member here is not, you know, the (juality of the people 23 involved because supposedly they have looked, but I can ask 24 them about regionalization becauc-o I think I know a little e ",at Repof ters, Inc. 25 bit about it. And if it's not there in it then that 1)(icoiiies L41 I issue in my decision. So I think vie will have at least at 2 review committee a chance to meld them together, whether or' 3 not we meld them on site or not, on individual site visits, 4 Any further comments on that? 5 Harold I have to say that's the most helpful, 6 succinct two minute statement that I have heard for some time 7 relative to this issue. 8 DR. MARGULIES: it's easy when it's categorical. 9 That's what is so attractive about it, 10 I would like to suggest that, if the committee is 11 agreeable, we might set up a period of time in the niornin- r> 12 for an executive session because it is quite apparent to me, 13 as I think it is to you, that You still have a sense of 14 discomfort over a lot of the things which we have attempted 15 to discuss today and the last time, and I think we might be 16 able to deal with them more effectively in an executive 17 session. We could do that first thing in the morning for 18 whatever period of time is appropriate to your time schedule. 19 DR. MAYER: I think that would be helpful and 20 appropriate, and probably first thing in the mornin- would 21 be a good time to do it. It would be an executive session 'O 22 consisting of the Review Committee and Dr. Margulies and 23 whoever else he chooses to bring. 24 All right, are you ready, Leonard, for the great Fedetal Repotters, Inc. 25 state of Illinois? 142 I DR. SCIFERLIS: So that's N,,,hy we are here, isn't it? 2 DR. MAYER: That's one of the reasons. 3 MR. IIILTON: Sliould 1, Dr. Mayer, excuse myself? 4 DR. MAYER: I suspect it would probably be appropriate. 5 1 think the record ought to show that Mr. Hilton has left, 6,' and also ought to show that Dr. Schmidt is not with us today. 7 DA. SCIIERLIS: The Illinois site visit was 8 conducted on December 15 and 16, last year. Dr. Brindley was 9 with us at the time. The other members of the site visit 10 included Dr. Vaun, who is Director of Medical Education 11 in Jersey. This is of significance because some emphasis of 12 the Illinois program is on continuing education. 13 By the way, about hoNi much tine have yoti,pliov,,ed for 14 each review? 15 DR. MAYER: I haven't divided it up. 16 DR. SCHERLIS: About an hour? 17 DR. IIAYER: That for review and discussion wou d 18 be fine. 19 DR. SCHERLIS:- About 15 or 20 minute review. 20 Other members from the, staff included Mr. Nash, 21 Public Health Advisor, Mr. piatek, Program Analyst, Miss 22 Hulburt, Dr. Girabol, and Mr. Ryan. 23 y profitable one The site visit I think was a ver 24i in the sense that we met the evening before, I think we knew @--Fcdet,il Repoitets, inc. 25 what our problems were as far as what some of the difficult 14ZJ 1 areas were that we had to OXPIOre further. I'le tried to 2 put most of our emphasis on these areas. 3 You all have the report. I would like to emphasize 4 some of the things about it. The report is organized on the 5 basis of our rating system. When Y;e do this I think you can 6 see it has some advantages, but at the same time it does 7 permit a certain amount of duplication. 8 We were impressed with the numbers of people who 9 attended the site visit representing Illinois. T 3s was 10 not alone important as far as numbers., but as far as the 11 groups which were represented. 12 We were most favorably impressed with the executive 13 'ector, Dr dir Creditor, who I think used the site visit 14 for many reasons, not alone to present the Illinois program, 15 but I think he was also manipulative in the sense that some 16 of the agencies which were represented -- he helped 17 utilize their presence to try to make some points with them, 18 and I think he did so in a Sense of trying to get them to 19 recognize what some of--the problems were which they posed for 20 RMP and how they might better cooperate. 21 The list is a most impressive one in terms of 22 not alone board members, but groups which were represented 23 from the entire community, many of whom had ti,.aveled a long 24 way. And I must say it was one of the better organized and I Repot te i s, itic. I- 25 most fruitful site visits in terms of having good 144 representation and the information which @,e desired made 2 readily available. 3 Our site visit charge was in terms of the fact 4 that the Illinois group has requested support for a core, 5 for projects of developmental components of its triennium 6 application, and so our charge was to review the region's 7 overall progress, to examine the experience and achievements 8 Of its ODgOin- program, determine how this would modify the 9 pro-ram goals, objectives and priorities, to review their 10 prospects for the next three years, and then to arrive at a 11 funding recommendation.. We attempted to meet all of these 12 scores as best we could. 13 The funds which were requested were as follows: 14 From the present base which for the 02 year is 1.5 million, 15 they had requested for the 03 year 2.8 million; 04 year, 3 16 million, for the 05 year 3.2 million, ",hich, as you can 17 see, is a most ambitious increase. It should be stated, 18 however, that their 02 year did represent a drop in level of 19 funding from what had been a previous year of, I think, 2.0 20 or thereabout. 21 The background of this group is that they now have 22 a board, a relatively new Executive Director, Dr. Creditor, 23 and we will get into that as we review our -ancral overall 24, at Reporters, Inc. impression. 25 I think our overall irqprcssioti was it was good, and 145 I then we tried to translate that into terms of documentation. 2 First of all, the region has made excellent progress 3 since its lost site visit in December, 1970. They have 4 established goals and priorities which are certainly 5 congruent with national goals, and I think practically every 6 region in the Country has a rather similar program for that. 7 And they have administratively a board which I will -et into, 8 they have a Regional Advisory Group, and they have an 9 organization which I think is a most effective one, 10 Their RAG does represent key health interests in 11 the region, is a responsible group, been able to make 12 decisions on a logical and well founded basis, and was quite 13 effective in carrying out it's responsibilities. It,, does 14 appear to us that RAG is the decisioiimakin- body of the 15 Illinois Regional Medical Program, with a heavy input from the 16 Executive Director, but the final decisi.oi)tnaking appears to 17 lie within RAG itself. 18 Their chairman is a highly capable individual. RAG 19 membership is involved in all levels. They have orientation 20 sessions for RAG, and their members take part in site visits, 21 and this has, I think, been a very important strength. 22 You will notice in our site visit documents several 23 references to the fact that they need more representatives front 241 minority groups. This is why I made the aside to i,ir. Hilton '-FedCI31 Reporters, Inc. 25 that I did earlier as far a,- Illinois was concerned. 146 I The Executive Director is an extrepicly knowledgeable 2 indivri(jual, kiioy,,s what is going on with the in Illinois.' 3 One shouldn't have to say that, but as a member of site visits 4 to other regions you sometimes find coordinators who are not 5 aware of the details of the program, and certainly their 6 coordinator is very, very well aware of all of the details. 7 He has been heavily involved with them, yet at the same time 8 has involved the other groups. 9 Those of you who may and I will just spend a 10 moment on this -- there is a unique arrangement in Illinois, 11 the Executive Director, Morton C. Creditoro and the Grants 12 Manager, Mrs. Una Creditor, who happens to be his wife, and 13 this is indeed unusuai;but as we spoke to other members 14 of the Illinois group and as we met with her I think she 15 should not be discredited by virtue of the-fact that her 16 husband happens to be Executive Director. I think they.are 17 fortunate in havin- both people worl,@in- there, and they both orer 18 ate, at Lea-St during the day, I think independently as far 19 as some of the objectives are concerned. So I don't think 20 this speaks of patrona-e. I think it speaks of the fact 21 that they happen to be riarried each to the other. 22 well, in addition to the Executive Dir ector as far 23 as the core staff is concerned he has a capable and energetic 24 group. In addition they have Dr. George Miller of the Fedeial Repoiters, Inc. 25 Illinois region, and the participates as the core project 147 I director. I will get involved in tliil-a a little more later. 2 Dr. Miller has been involved almost more than a-tiyone 3 else in the country with continuing education for physicians, 4 and his participation as a men-tber of the core group is 5 very important. 6 We did suggest that they have somewhat better review 7 periodically of their own core projects. This riay becoine an 8 issue that RMPS ha-q to consider more and more, the fact 9 that there are such good technical reviews of individual 10 projects, since more and more of those are supported by core there has to be technical review in addition of core, and 12 how this can best be done may be a question of lo-istics. 13 But this became apparent to-us more and more during the 14 period of our site visit. 15 In Illinois the CIIP agencies have been very slow 16 to develop, and Regional Medical Programs coDt.ri.bute markedly 17 particularly toward the development of B agencies. So a lot 18 of the subrogionaliza'tion of Illinois has been through 19 the vehicle of the B agencies of Comprehensive Health Planning. 20 r lie has, I Now since their new coordinator took ove 21 think, given the whole Illinois Regional Medical Program 22 a sense of enthusiasm and of movement which had not been 23 there previously. 24 And if I can'now go into individual items, they Rc!rjoftcls, Inc. 25 reformulated all their goals this summer, and RAG is very 148 I strongly involved with the whole RNIP program, and as a result 2 they printed a manual flyer, and I think this is important. 3 It has had wide distribution. And this specifically states 4 what the objectives and goals and the funding procedures 5 are. This has been of importance as far as everyone who 6 submits a project knowing what the ground rules are before 7 they submit the projects. 8 These objectives include the following: "Improving 9 health care delivery by makin& existing systems as effective 10 as possible and catalyzing the development and evaluation 11 of potentially effective alternate systems.ft 12 As an aside, they have used core funds very 13 effectively to help catalyze developments. They have used 14 three or five thousand dollars as support projects which 15 have been able to utilize these funds to grow and project 16 the influence of these goals further than I think largely 17 projects have elsewhere. 18 Goals B is "increasing the availability, efficient 19 utilization, and capability of health care personnel throughout 20 the IRIT," and goal C, "controlling those major medical 21 problems which cause economic loss, social distress, physical 22 and emotional disability, morbidity and mortality." 23 They are pretty good goals, I think they are quite 24 inclusive, and I would find it hard to fault them as much -Federal Reporters, Inc. 25 as I would try to fault motherhood. 149 They give priorities to all activities as best they 2 can on@the basis of A, B and C, in that order, and they 3 try to look at these very carefully. 4 One suggestion we made is that they set up some sub- 5 goals on the broad general basis of these three. So we did 6 suggest that they have some subgoals and smaller objectives. 7 listed. 8 They have shown that they can terminate some 9 projects, and they have terminated two of them on the basis, 10 I think, of good critical.review; one on the basis they had 11 not set up adequate evaluation, had no data that would 12 indicate any success, and the second on the basis, too, that 13 no further funds be awarded because performance was 14 inadequate. So they have shown that they can criticize 15 their own programs even though they had been previously funded 16 As far as specific accomplishments and implementation 17 are concerned, they supported projects of improving cancer 18 programs, a coordinated cancer program which has involved 19 throughout the region several hospitals. They are having 20 some problems with this because as other hospitals improve 21 their facilities some of them utilize the central one 22 less, but certainly this gives some hope as far as being 23 able to continue them. 24 ,ce-Fedetal Reporters, Inc. They have set up a coordinated home health_project 25 in northern Cook County, a comprehensive health program. They have multiphasic screening programs in the Chicec,,o area C, 2 industrial plants to detect coronary prone individuals, 3 have stroke rehabilitation services, and all of these read 4 as you might expect since this is a list of what they have 5 had in the past as their whole categorical view and 6 emphasis. But the ones that they have had have been well 7 surveyed. They have met with the review, which I will get 8 into, which appeared to be extremely effective. 9 New activities which they are proposing include 10 home health services, a system of planning care, computerized 11 hypertension treatment, Winnebago County comprehensive care, 12 continuin- education for Mid-Southside. And all of these 13 are' directed at delivery systems. They have set ur 14 programs which help support ongoin- community health and 15 medical care systems and to help evaLuate them. 16 They are very concerned with the whole process of 17 evaluation and are looking in their area under the 18 continuing education program at the whole concept of having 19 a much better method of peer review, and to this the-y are 20 looking at program oriented charts as@ their standard, And 21 they regard this as an important decision because they hope 22 that by setting up method score evaluation, utilizing 23 specific problem oriented charts .,i,@ the hospitals and HMO'S, 24 that th.is would give them a way of looking at success or failu -E %ce-Fedeial Repoftefs, tnc. 25 and patient problems, and they do have the medical societies 1interested in this-as l@,ell as their own evaluation groups. 2 The core activities are extremely extensive, and 3this is why I mentioned they have used small funds to try to 4move in certain specific directions, including support of 5their educational support resources. This is the general 6area which is under Dr. George Miller. It has been very 7effective, and the question we had about this was the need 8 for technical review from the outside. 9 They have the north Suburban Association for Health 10 Resources, Nlid-Southside Health Planning Organization. They 11 have been inv olved with home planning on a very active basis. 12 If-Audit of Family Study of Physician Referral Services, Se 13 Practitioners. They have been involved in a whole series 14 of surveys of health needs, and so on. 15 I mentioned their minority interest, but in passing 16 Jost to summarize it, on RAG 4 of 47, nine percent 17 minorities on committees, four percent core professional staff 18 24 percent for secretarial staff, 43 percent project 19 professional staff -- the way it averages out it comes 20 to -- I don't have a final figure on that, but you can see 21 there is a wide scattering. There is less than proportions 22 minority population in the state. Twenty percent that 23 represent minorities, 13 percent black, 6 percent Spanish 24 surname. @ce -Federal Repof teis, Inc. 25 As I said, Dr. Creditor is a very effective, dynamic 1 force in the Regional @',edical Progrm, has changed it since 2 he took over, and that Nyas only on June lst, 1970. These 3 changes have really been done very rapidly, 4 Core staff -- they have 21 full time members, and 5 they do have some vacant positions which they are trying @6, awfully hard to fill; heavily involved, as I have indicated, 7 in continuing education through that center supported project, 8 some.very heavy involvement with other objectives. 9 Administratively they have a board of directors 10 which has reorganized so tha t it now has only fiscal 11 management, specifically manages fiscal affairs of the 12 corpcr at ion. We looked into this because we were concerned 1.3 as to whether or not it 'became involved with poli@,ies. The 14 board does not. It is purely fiscal and personnel concerned. 15 It has nine members, six of whom represent the schools of 16 medicine or osteopathy. Two of them are teaching hospitals. 17 So all of this is very heavily oriented toward the medical 18 school, and is purely fiscal-personnel, and by every way we 19 could we did establish satisfaction that it is purely on.that 20 basis. 21 I have already read the -oals to you. I won't go 22 ahead with that. 23 Its organization, to move further with this, they 24 have six standing committees, all of which are chaired by Ice-Federal Reporters, Inc. 25 So the members of RAG. re is a heavy involvement by RAG. 1 These are the usual, executive, nominating, review, health 2 care delivery, and so on. These are riot categorical. In 3 addition they have committees which are categorical. 4 1 think they are really fortunate in their leadership 5 and involvement in RAG. 6, The review process is an excellent one. As I have 7 said, they do have published criteria and published 8 priorities, so that when a letter of proposal comes in it 9 is easy for the proposer to determine whether or not it 10 fits into the priorities of IRIIP. Staff works informally 11 with them putting together the original application. It 12 goes to a technical review committee before it goes to the 13 overall RAG group. And the review committee is one which 14 gives out excellent reports.. 15 As far as ongoin- project surveillance they have 16 adopted a project review which is excellent, and they 17 evaluate the projects anywhere from two to four times a year, 18 with at least four times a -year looking at it from a budgetary 19 point of view. They carefully go over items of the budget 20 to see whether or not funds are being expended in the direction 21 and this has been in which the grant was originally made, 22 of help to them in rescuing significant amounts of funds of 23 ey have been able to core supported projects. In addition th 24 maintain a quality of control by these frequent reviews which @rt,,-Fedeial Repottefs, lnc@ 25 appears to be of a high level. 154 We were'impressed with the degree of involveiiont of 2 local agencies. As we said, the A and B agencies in Illinois 3 leave a great deal to be desired. Dr. Creditor utilized'the 4 format of the site visit to ask questions of the A and B 5 agency representatives, which I think will get them off the 6 center in many respects as far as knowing what their 7 involvement should more strongly be. The worst criticism 8 was made in terms of their not having developed overall healtt 9 plans. 10 m between the There appeared to be some schis 11 IRMP and the CHP in the regard that Dr. Creditor repeatedly 12 stated that the planning had been minimal and he assumed 13 that this was the prime role of the comprehensive,,health 14 planning, but in reality privately he informed us that they 15 obviously were involved in planning as well, but were hoping 16 that the CHP Would be more involved both with the planning 17 and evaluation. They have been of little help in 18 evaluating projects as well. They have often left a great 19 deal to be desired. I think the site visit group felt these 20 criticisms of the CHP were indeed justifiable. 21 They have been very, I think, effective as far as 22 their educational programs are concerned. They have 23 established strong relationships not only amongst the medical 24 ,ce-Federal Repottefs, Inc. centerIS, but certainly amongst the surrounding communities 251 in addition. They have set up what they referred to as articulated systems of health care. These projects include 2 home health services, the Illinois kidney disease program,- 3 radiation therapy program. They help to develop models 4 of IIMO'S. And this is not reflected in the amount of money 5 they have spent, but they have utilized their staff heavily 6,, and small amounts of funds as' catalysts in this regard. 7 They have functioned as the liaison amongst the 8 35 developing HIAO's of the state. So if anyone is concerned 9 about how many there are in the country I think that the 10 amount of funds mentioned this morning.don't really indicate 11 either the number or the level of support because so much 12 of core staff activity around the country I think is 13 going into this, and it does not get reflected in terms 14 of the funds which are actually iis ted. 15 They are anxious as far as developed advanced 16 tech nology in health care, computerized hypertension services 17 There was excellent representation from several of the 18 developing HMO's in this area, and these I think are very 19 heavily involved with the Illinois Regional Medical Program. 20 Some of the specific projects include a radiation 21 therapy treatment plannin- center which helps to serve severa.. 22 medical centers; the Illinois kidney disease program, 23 which again is one that has many different areas involved 24 with it, appears to be a good overall program, but they, as I Rer)oiters, Inc. 25 they have admitted, have had little influence on discouraging i56 which sporadic renal transplant surgery in other centers, 2 the three in Chicago appear to be developing quite well. 3 They are involved with a comprehensive family oriente, 4 community health center to help a poverty area of some 5 10,000, and this is the so-called Valley project. 6 They are also involved with the Hyde Park-Kenmood 7 planning for care which will involved some 45,000 residents. 8 I won't continue describing some of the details 9 except to state that we were impressed that this was a 10 region which, given funding, would be able to utilize it I I effectively. They have shown the ability as far as leadership 12 is concerned, as far as having a RAG which reaches 13 responsible decisions, as far as having bud-etary controls so 14 that it can cut off programs which are not effective, as far as 15 rescuing funds from these projects and utilizing them I 16 think with good judgment. They have good technical review not 17 only for now projects, but for those which have been 18 continuing, and not hesitating to cut them off. 19 I think there is a heavy involvement with the problem 20 of delivery of health care services and with input from, I thin]:, 21 many of the projects which are going on in the Illinois area. 22 I think that given X funds they would be able to 23 use these funds quite well. So our concern was not on their 24 ability to utilize funds. ice - Federal Reporters, Inc. 25 We felt that me would approve them, and recommended this number one, we approved their pro-ram of triennial 2 status; number two, that Nye approve the developmental component 3 request; that we approve the request for core and projects, 4 all of this in a somewhat reduced amount. 5 We felt that they had the capability and maturity 6 and program to justify the amount which we will recommend. So 7 we got together our ouija board, and we decided that the third 8 nded 2.65; year they had requested 2.8.5 million and we recomme 9 for the 04 year they requested 3 million and the fifth year 10 3.2 I will go over that again the third, fourth and fifth 11 -years,they requested 2.84 million for the third -year, the 12 fourth year 3.0, the fifth year 3.2. our recommendations for 13 million, each of those years in order were 2.65 million, 2.$, 14 and 3.0 million. 15 We feel this is one of the-better regions as far 16 as being able to utilize these funds, that there is the 17 adequate opportunity in the region to do this, and therefore 18 the site visitors so recommended. 19 DR. MAYER: Dr. Brindley. 20 DR. BRINDLEY: I agree with everything that has been 21 mentioned. I had the opportunity of reviewing the program 22 a year ago, and it was of some interest to compare the 23 changes of a year ago and the press n't'- condition of the 24 A@ program. al RePorters, Inc. 251 Strong points to me were the coordinator -- he is i58 I intelligent, aggressivct eager, and a good salesman. The -0 2 RAG is a very good one. It meets freqtjently. They are 3 enthusiastic. There is representation from all fields. 4 There is a very good relationship with the Governor's 5 office, and they do keep good rapport with all the other 6 agencies except the Comprehensive Health Planning. The 7 tin- Comprehensive Health gentleman that was there represen 8 Planning was nervous, concerned, really wasn't able to 9 propose a very good program, and apparently they haven't done 110 their part too well. That is not directly the responsibility 11 of the R@IP, but it does hinder their program that they 12 haven't had very good assistance from the CHP, particularly 13 in planning. 14 There was marked improvement in the program over the 15 past year. Last -year they were just-beginning to sit down, 16 change their program, change their bylaws, agree on what they 17 might try to do, and they have made a lot of progress 18 in the last year. 19 They have an-,excellent method of evaluation and of 20 developing projects and programs. They have a very good method 21 providing funding and shifting those funds to areas of need 22 and reducing funding from programs that are not very productive. 23 Points of concern to me, when we were there a year 24 ago we asked them at that time have you evaluated needs in your @@ce - Federal Repottets, Inc. 25 state, your abilities to meet those needs and proposals to 159 I accomplish these and they said at that time well, they were 2 just about to do this, and Coinprehensive Health Planning 3 was going to help thorn with it. We come back again this 4 year and no one still has done it. Comprehensive Health 5 Planning hasn't done it very well. And as far as I could tell -- as a matter of fact, they make the statement that 7 they haven"t done this because it was too late when they 8 got started and now the programs are going around it, and 9 so we Just haven't gotten around to doing this, that these 10 objectives;and programs we have are all.good, they are 11 national programs, people are bound to need it, and so we are 12 just going to move right on into this. 13 Well, I'm old-fashioned enough to think,@t might 14 have been better if they would have looked at real needs and 15 abilities to accomplish those, and I don't believe they have 16 done that as well as they might. 17 hat point, DR. SCHERLIS: Let me just respond to t 18 We were concerned about this, and I think you left after t 19 first day, so we met specifically with their program 20 coordinator and said you actually put out a letter which 21 stated -- and the letter specifically stated -- let's see, 22 1 have it right here --"as a matter'of fact, it should be 23 emphasized that the Illinois Regional Medical Program is not 24 the result of systematic collection, collation, analysis 'Ice-Fedetal Repotteis, Inc. 25 interpretation of data, e.t cetera.'* lye said what data do itiv I you have. He said "all the data we have are dirty." We 2 said we would like to see it anyway, and then he brings out- 3 replete volume after volume after volume of really very good 4 data, and I don't know why they put that ploy in. 5 Who else was on the site visit? 6 This was a very peculiar ploy, because we asked them 7 for data and they had some of the best analyses of health 8 data that we have seen, and when you think about Illinois and 9 their Chicago'health system, and Dr. Stan and other.s who collei-t 10 ed down in that area., they hae some very good data. 11 I think what they are emphasizing is there are 12 certain obvious needs that you can't get very clear data 13 on,' because we took them to task on it and they brought out 14 document after document, beautifully evolved. 15 Perhaps you can comment on that later as a member 16 of staff. 17 DR. BRINDLEY: The goals that they mentioned to us, 18 of course, are national goals. They are certainly excellent 19 ones, but they really didn't have very good subgoais or 20 intermediary points of achievement, even though they could 21 improve on that. 22 The program still is largely Chicago related, They 23 did take the pledge and.promise that they are going to 24 develop some regional goals and are now-going to g,.. kce -eral Repoitets, Inc. 25 with this and improve it. Butthey haven't done as much as the 161 mi ght in that regard. 2 Relationships with the CIIP still were not as good 3 as they could be. 4 And then I was still concerned some about the size 5 of the budget for core.. I realize that core is essential, 6 and it is very important and does lots of thin-s other than 7 administration. But it is about half of the total budget 8 for the area, and although.wili be increased will still be 9 at about half. They are going to double the size, they 10 need to increase it some. But I just wondered if that is 11 the best way for them to use their money. They are going 12 to add three more people for the problem oriented record, 13 which we think is probably funded higher than it should 14 be, and three more physicians are going to join core to look 15 into this. 16 So I did have those concerns. I don't mean to be 17 unkind. I think they have made great improvement and it 18 is much better. It did seem to me there are some areas 19 where they could further improve. 20 DR. MAYER: The recommendation let me see if 21 1 am clear. With their current funding budget at roughly 22 a million and a half, which is really on a 14 month base, 23 which translated back would be around a million two or so, 24 what 'you are essentially recommending is a doubling of @ce-Fedetat Repottels, Inc. 25 their operational activity. I just wanted to make sure that I we are all clear on that. 2 Okay, discussion. 3 Yes, John. 4 DR. KRALEIYSKI: The question on that core staff, 5 I think that is a good one. Do you think they will be able. 6 to recruit -- they are going to recruit 22 people, is that 7 their plan., to add to that staff? 8 DR. BRINDLEY: Yesp and they have listed the 9 categories they are going to try to fill. They didn't say the@ 10 had those men available or they could get them, but that 11 was their aspiration and they are budgeting for it. 12 MISS ANDERSON: Do they have job specs for them? 13 DR. BRINDLEY: Don't push me too far. I've got 14 the names down here. They do say they have those needs, 15 and they related primarily as getting into the subregionalizati( 16 effort. We are now going to go out and address regions and 17 have two more schools. 18 DR. SCHERLIS: Illinois has a very rap idly expanding 19 medical school system, and.they are subregionalizing through 20 that area. 21 Let me'make one point that I perhapsehould have 22 mentioned. Council had originally recommended for the 23 second year two million dollars, They were funded at a 24 16vel'of 1.5. As they pointed out, this.is probably the best al ReporteFs, Inc. 25 thing that happened to Illinois because they just had to 163 I constrict everything they had. It gave them the opportunity 2 for a total re-evaluation of all the system with which 3 they were involved at the time. 4 Much of the increase will be core. As I have 5 indicated, core is very peculiarly competent I think in the Illinois program. They have some of the best people, I 7 think, around, both as far as evaluation in the field of 8 education,, and I think the whole problem of evaluating 9 quality of care with HMO's can be greatly helped by the 10 sort of program they are discussing in.Illinois. 11 I think that as you look at their core project it 12 is a very ambitious one. There's no question about it. But at 13 the same time they have, I think, the energy and the ability 14 and a RAG which will permit them to utilize these funds. 15 i.am impressed that that state will have very 16 little waste because of their method of budgetary control 17 and review and the priority systems they have worked out. 18 I would not be as happy about giving these funds to many 19 other regions. I think this region can handle it very 20 effectively, and the health needs in Illinois -- you know, 21 this is a hu-e state, and you talk about increasing it 22 2.6 million, 'you think about the size of Illinois and they 23 are getting involved now with delivery of health systems, 24 this is a very, very expensive area. ,ce-Fedeial Reporteis, Inc. 25 DR. KRALEU'SKI:- Do they have any vacancies on core 164 I right now? nted 2 DR. SCIICRLIS: They hav e:,a few, but as I poi 3 out, they have hesitated to fill them because they had no 4 idea how much attrition there would be this year. The 5 signals from Washington waxed from little support to a lot 6 of support. And they have been hesitant,for a lot of reasons, 7 to hire people knowing they might not get support after a 8 few months. 9 I am not concerned about their filling them. From 10 what I can see, the morale on the staff is so high they 11 should have no difficulty attracting desirable people to 12 work there. 13 The whole feeling 'you get about the IRI@T is one 14 of organization and is moving along very effectively, and 15 not just stars in its eyes, but knows how to utilize the 16 health dollar. 17 DR. MAYER: How realistic do you think their 18 pledge that they took, Dr. Brindiey, to got outside the 19 city of Chicago was? That's a big state. 20 DR. BRINDLEY: Well, in speaking to Us they seemed 21 sincere and genuine that they were going to make a real 22 effort to go to the other areas, and they shoNved us a lot 23 of maps and where they planned to go and how they proposed 24 to go about it, and particularly with the new schools ce-Fedetat Reporters, Inc. 25 and area health education centers as it related to those I I schools, community clinics in those areas, They did show soinf 2 health plans, home health care plans that would involve 3 other areas out of the Chicago area. They sounded 4 encouraging. 5 DR. MAIRER: I just wanted to make sure %,e had asa ,6 matter of clear record so that next 'year we could took at 7 that issue and see how far they have come. 8 DR. SCHERLIS: There were three negative 9 recommendations. One, they had to have increased minority 10 representation on the RAG. lye discussed this at some length 11 with them and I think they are impressed with the fact that 12 this,is a very high item of priority as far as we were 13 concerned. 14 Nutfiber two, more clearly defined subgoals and 15 objectives; objectives including onesfor core activities and 16 educational support resource activity. I referred to that. 17 That's Dr. Miller's activity. 18 We also emphasized they had to be able to 19 evaluate core projects technically. 20 And three, increase planning activities directed 21 toward subregionalization of program. 22 The CIIP agency was one which I think should work 23 more effectively, and I think part of their emphasis on 24 not having data is they want CHP to be more directly involved kCe-Fedetal Repofteis, Inc. 25 with planning and helping to get som additional data, 1 CJ6 You are concerned about the Sum of money we are 2 recommending, I gather. I ean not. 3 DR. l@IAYER: No, I just wanted to point out we were 4 doubling the budget of a region, that's all. 5 DR. BRIITDLEY: It is encouraging, I think,-from 6 the minority viewpoint that the man in charge of that is 7 a member of a minority group. He is one of the professional 8 members of core. It is his job to go out and recruit and 9 to find these people. He is a very ener-etic, enthusiastic 10 person, and said he was making a real effort to find these 11 people both for involvement in the core and also in the RAG. 12 I think they are trying their best to get good members. 13 DR. MAYER: Other comments? Questions of the two 14 reviewers? 15 MISS ANDERSON: I was just wondering here on the 16 core staff aspect where they are sort of contradicting 17 themselves, where they are talking about regionalization 18 and extending out to the rest of the state they ask for 19 three part time staff,.a specialist for Northwestern 20 University, Western Presbyterian, Chicago Medical, and they 21 are all i-n the Chicago downtown area and not spread out. 22 DR. SCHERLIS: Don't forget the very heavy 23 population which centers in Chicago. They are attempting 24 itt,-Fedeial Repotters inc. something which if they can carry it off it will indeed be 25 excellent experience, and that is to get-each of the medical 167 schools to take a portion of Chicago as its area of 2 responsibility for the delivery of health care. And in doing 3 this they had the temerity to actually put lines on a map, 4 and this takes an unbelievable amount of gall, I guess, 5 to try to convince deans of medical schools that this is the Na 6,- to do it. And part of their attempting to do this involves 7 having support of the schools. 8 We were impressed with the involvrnedt Of the 9 medical schools in their overall community outreach programs 10 in Illinois, and the fact that we always had at least two deans in attendance throughout this time, though if -you 12 look at where the money is going it is not going to the 13 medical schools. 14 DR. BRINDLEY: I think there was @an improvement in 15 the rapport with the physicians and hospital administrators. 16 When we were there before, why, they weren't too happy 17 with each other, but that seemed better this time. I tail,,e d 18 with several of the physicians about it, and they were 19 more enthusiastic. 20 DR. TIIUR@IAN: You don't see any turf problems as 21 they refer to them? 22 DR. BRINDLEY: oh, sure. But they are doing the 23 best they can with that. 24 DR. TIITJR"IIAN: As long as they can breathe they are ed,,,l Repoftets, Inc. 25 okay. DR. MAYFR- other questions? John. 2 DR. KRALU,,WSKI: I understand -you think it is a good 3 program, and I am in agreement. I am sure they have some 4 good things going, but one question -yet I have on that core. 5 If they are goin- to add that many people they are probably CP 6@' going to have to phase them iD over a period of time, and 7 are probably not going if they are going to do that they 8 to budget, and did your be able to spend that core 9 cutbacks reflect that -- that's where your cutbacks were? 10 So they will probably.be able to phase this group in and 11 extend that budget out in that way? 12 DR. SCIIEP.LIS: I really think so because many of 13 these projects in which they ask support are already 14 beginning to move along somewhat. I think they have people 15 in mind for many of them. 16 I think it should be emphasized, too, that their 17 coordinator has been there a very short. period of time, 18 is just beginning to turn programs around, and he has already 19 fixed in his budget for heavy amounts. If he is going o 20 have any impact it has to be by way of funding and new 21 directions, and we put a lot of our faith in his ability to 22 do this on the basis of what he has done by rescuing small 23 amounts of money by stopping projects, and taking that money 24 they weren't going to use. With RAG and technical review they ,,e- ede,,l Repoitefs, Inc. 21 have phased out projects on the basis of not measuring up to 169 .1 standards, not havin- adequate revie@,i, or not putting funds 2 where they should go. They haven't hesitated to do this. 3 MISS KERR: I got that the first time, but did 4 I miss anywhere along the line where you referred at all to 5 their turning over of projects or activities for outside 6 planning? Are they phasing out any support from the outside? 7 DR. SCHERLIS: This is a very heavy criterion as far 8 as their review process is concern. This is one of the 9 very strong points. i 10 tm. TOOIKIEY: As they have divided up the city of I IChicago have they kind of adopted on a satellite basis 12 hospitals within the area to relate to one of the medical 13 schools or the hospitals have a multiplicity of-- 14 DR. SCIIERLIS: I should emphasize even if they draw 15 lines on the map these are real thick, heavy, fuzz-y lines 16 because some hospitals here work with community hospitals 17 oOt here, and they are just beginning to move in that 18 direction, but as I said, it looks like they are doing it, 19 and they do have satellite facilities with hospitals 20 as part of this program. All of %this is just beginning to 21 evolve at this point. 22 Mft . ..TOO,@,M@ Y: Is the relationship just medical 23 between in the hospitals is it the medical school or is it 24 relating to administrative as well? Repottets, Inc. 25 DR. SCliE@RLIS: Their allied health professions are I - 170 Iinvolved very heavily. They have administratively 2can't speak to this. We had specific items that related to' thEt. 3 DR. MAYER: Further comments? 4 MR. NASH- Dr. Scherlis, you seem to be so concerned 5about the size of core. This includes, of course, Dr. Iiiiierg, 6 project. 7 DR. SCHERLIS: I think that is an important point, 8 that when they talk about core a lot of our curiosity centered 9 around the fact that within core they had some areas of 10 activity that might be funded as projects elsewhere. This 11 is particularly true of their educational resource center 12 under Dr. George Miller. And so a good part of that core 13 fu'ding is through Dr. Miller, We suggested that they look n 14 at this administratively as well in order to.not just let 15 this be an ongoing project through core. One reason they set 16 it up is because they had it funded three years 3-n a row 17 and it is a continuing resource for the state, will now 18 become heavily involved with their own problem oriented type 19 history. 20 But I appreciate that addition. This is one reason 21 why core is so-- 22 DR. KRAIYLEWSKI: Are they goin- to phase out that 23 project or do they plan to stay in it forever? 24 DR. SCHERLIS: I think if you look, they will be Ace-Fedetat Reporters, Inc. 25 in it a while longer. We did as one of our suggestions 171 emphasize they look at that whole administrative structure 2 and set up some ongoing technical review of it periodically. 3 So this won't be free swinging. It is a wonderful resource to 4 have in the state and should be there. The question 5 obviously is how long should it continue to be supported by 6, RIIP. It should be added that this is not a major part of 7 the support by any means. He has a great deal of support 8 ongoing. I guess from the whole manpower and other agencies. 9 DR. PERRY: The Kellogg Foundation has just- 10 funded a half million dollar project. 11 DR. SCHERLIS: This isn't something he needs only 12 for this. These funds are specifically related to RMP 13 activities. 14 DR. MAYER: Other comments? 15 Then -your recommendation is two million 650, 16 two million eight, three million respectively. 17 DR. SCHERLIS: Yes, I make that in the form of a 18 motion. 19 DR. BRINDLEY: Second. 20 DR. MAYER: Discussion? 21 All those in favor? 22 (Chorus of "ayes.',) 23 Opposed? 24 (No response.) ,ce-Fedeial Repoiters, Inc. 25 Well, let's tak.e a minute to fill in the blanks while we have a chance, remembering that 5 is the highest, I 2 is the lowest, and circling those that you have some guilt' 3 about. 4 DR. SCHERLIS: You are not requesting members of the 5 site visit to do that, are -you, because ours is already a 6 matter of record, andI don't want to be caught in any 7 inconsistencies. 8 DR. MAYER: Can it be recaptured? 9 MR'. NASH: I have one from Dr. Scherlis. I don't 10 believe I got one from Dr. Brindl'ey. 11 onard, it sounds Like you are DR. IIAYER: Le 12 excused and Dr. Brindley is not. 13 DR. SCIIERLIS- I am safe. He has mine. 14 DR. MAYER: I think we might move,on then, Sister 15 Maryland. Ann, to 16 SISTER ANN JOSEPIII@: All right. The Maryland 17 site visit-- 18 DR. MAYER: The record will show that Dr. Scherl s 19 has left the room. 20 SISTER ANN JOSEPIlIh'E: The Maryland site visit ,vas 21 made on December 8 and 9, and members of the site visit 22 team were Dr. Alexander Mcphedran, Emory University Ciinic., 23 and Dr. William l@IcBeath, who is the Director of the Ohio 24 Valley Regional Medical program. Staff present at the site [-Cdetat Repc)i tets, Inc. 25 visit were Dr. John Farrell of the Health Maintenance 173 organizations Division-- IV8 were very happy to have him Nvith us because a substantial, portion of the grant request from 2 Maryland is for health maintenance organization related 3 4 projects -- Mr. Harold O'Fialierty, from the Planning and 5 Evaluation Division, who prepared a very provocative list of 6 questions that we used the first evening prior to the site 7 visit to kind of get on the same wave length so that we 8 could evaluate the type of inquiry that we were going to conduct 9 as the site visit progressed; @Ir. Clyde Couchman, the 10 regional office representativ e from Region III; and Mr. George 11 Hinkle from the Eastern operations Branch. And we had 12 requested Mr. Hinkle to prepare a document that indicated the 13 questions that the previous site visitors had had ,tand then 14 to also indicate what corrections had been made so that this 15 would also serve as the basis of discussion. 16 Following the discussion evening prior to the meetin- 17 we decided that it might be of advantage if the chairman 18 of the site visit team were to meet with the coordinator, 19 of the program at breakfast so that possibly a good rapport 20 could be established between the site visit chairman and the 21 coordinator which would facilitate the site visit. And I 22 think that we had not done this on previous site visits I 23 have attended, and I personally found this very helpful. 24 The Maryland Re-ional Medical Program will have @re- -Federal Repo( teis, Inc. 25 completed its first three years as an operational progra-m on 174 I February 29, i972. And the present application was for a 2 triennial award, and they also.requested a developmental 3 component of $100,000. 4 The purpose of the site visit was to assess the 5 region's overall progress, the quality of the current 6 program, and its prospects for the next three years and 7 its ability to handle the developmental component. 8 One of the points that was obvious the evening 9 before the site visit began was that the Maryland Regional 10 Medical Program has responded to the directives from the 11 national program in such a way that the program represents 12 almost a .180 degree shift in goals and priorities and 13 empha is. And it should also be Doted that this i@ a program 14 that has experienced a high turnover rate in coordinators. 15 In the five -years of the program there have been five 16 coordinators. 17 nator, has had some Dr. Davens, the present coordi 18 involvement and has been interested in HMO'S, which is also 19 reflected in the proposals that have been made. 20 organization Johns Ilopkins University is the grantee 21 for the Regional Medical Program. And in the state are the 22 two medical schools, Johns Hopkins and the University of 23 Maryland. 24 On the prior site visit the site visitors were Ace Federat Repotteis, Inc. 25 disturbed by the fact that it appeared that the Regioii,3.1 175 I medical Prorram was heavily dominated by the two medical 2 schools. 3 The site visitors found that the Maryland 4 Regional Advisory Group has been expanded from 27 to 35 members, and this in response to a criticism on the last site visit, 5 6 and the total committee structure has been changed. Five 7 of the twelve committees which have been established to 8 assist the coordinator and the RAG are of categorical 9 nature. Three have been recently established following 10 successful core supporting feasibility and planning studies. 11 Two are structured; they are the health care delivery 12 Maryland health data, and patient health education steering 13 committees. Two are structured to relate to th6.core staff 14 administrative organization; and one, the Western Maryland 15 Regional Advisory Group, has been recently established to 16 provide greater peripheral representation. 17 In each instance the committees have a written 18 charge developed in part by the discussions among the 19 committee members, and the advisory committee which has been 20 set up advises the coordinator on the general matters of 21 policy and procedures. 22 The coordinator is supported by a staff consisting 23 of 18 professionals and 14 secretarial-clerical personnel, 24 of which five positions are part time. ,ce -Federal Reporters, Inc. 25 The core staff organizationally consists of the 1.76 coordinator, business manager, an associate coordinator 2 for project development, members of the Epidemiological 3 and Statistical Center, and the Division of Health 4 Manpower Development and Continuing Communication. 5 The core staff has been strengthened considerably 6 since the last site visit, and the site visitors were very 7 impressed with the chairman of the Health Manpower 8 Development and Continuing Communication Division. 9 Organizational changes have been made in an attempt 10 to provide a broader base for management and also to try to 11 eliminate the domination of the two medical schools in the 12 area. 13 gy 'nd Statistics Center, Which is The Epidemiolo a 14 associated with Johns Hopkins Medical Center, has been more 15 closely tied to the central core unit, and is now functioning 16 as the principal health intelligence and evaluation arm 17 of the Maryland Regional Medical Program. Previously there 18 was some concern that this center was funded as a unit within 19 the core structure, however,it was functioning independent 20 of it. 21 In the guidelines that were developed and published in 22 August of 197i for the Maryland Regional Medical Program a 23 very fine eviuation procedure. is described. However, during 24 the course of the visit as we questioned the individuals who al Repoitels, Inc. 25 were presenting the programs at some points it wasD't too 177 clear exactly how the F, and S Center has been providing an 2 ongoing evaluation service. 3 In response to change in direction expressed in 4 the RMPS new mission statements, Dr. Davens reported that 5 the medical school involvement in Regional Medical Program .6 activities has been redirected from continuing education 7 to planning and development of health maintenance organizations 8 and training of health professionals and new types of health 9 personnel. 10 The director of the Epiodemology and Statistical 11 Center, Dr. Leon Gordis, is moving to direct the efforts of his 12 staff toward the new mission of Regional tiedical program, 13 especially in the areas of collection and analysis,,of data 14 with specific reference to defined areas where there is interest 15 in and need for the development of a health maintenance 16 organization and area health education centers. 17 Dr. Davrens reported that since the last site 18 visit one of the crigicisms that was made was that there 19 was no evidence of cooperative efforts with Comprehensive 20 Health Planning, and this could be documented at the 21 present time. 22 There is increased minority group representation. 23 There has been a discontinuance of the University of 24 Maryland tissue typing project, and Dr. Davrens repeatedly cc Fedefal Repoliets, Inc. 25 reassured the site visitors that although the medical schools I 178 I support the Regional Medical Pro-rain they do not interfere 2 or attempt to control the program. 3 In view of the recent changing emphasis in the 4 strategy of Regional Medical Progrgms, the site visit team 5 elected to evaluate the Maryland Regional Medical Program 6 goals, objectives and priorities with respect to the proposed 7 new as well as past activity. 8 The goals, objectives and priorities are clearly 9 and explici tly stated, and the site visit team was 10 impressed with the fact that the objectives proposed for 11 the triennial period clearly reflect the objectives, goals 12 and priorities that are stated in their application. 13 DR. MAITR: Excuse me, Sister, did vou s are 14 explicitly stated or inexplicitly? 15 SISTER ANN JOSEPH'INE: N9# they are explicitly 16 stated. However, the goals are in response to the recent 17 direction given to Regional Medical Programs. 18 DR. MAYER: It looked like a perfect rewrite to me. 19 SISTER ANN JOSEPHlh'E: That's right. That's right. 20 This is one of the disturbing things, I think, as we evaluated 21 The emphasis during ghe discussion and in the 22 submission of the projects, the emphasis on health maintenance 23 organizations, area health education centers, again was 24 stated in such a way that it was a direct restatement of the ce-Fedetal Repotteis, Inc. 25 directives from the national program. 179 The Maryland Regional Medical Program has made 2 substantial change in program direction, and one of the things 3 that disturbed the site visitors was that some of the 4 projects that had been implemented in previous years seemed 5 to be dropped without any planning or any phasing out 6 and new ones added, and it appeared to us that probably this 7 was done in an attempt to meet the newly established objectives 8 rather than followin- careful evaluation and in response 9 to the needs in thecTea. 10 The two projects for Hilo's were passed by RAG, but 11 were not subjected to the evaluation and the technical 12 review process that are very well described in the guidelines, 13 and the same is true of two other projects that wd!re 14 submitted under new projects. 15 The RAG -- although the membership of RAG has been 16 increased, the site visitors were disturbed that the majority 17 of the members of RAG come from the Baltimore area, and 18 there does not seem to be the type of representation needed 19 to better understand and respond to the needs of areas 20 peripheral to Baltimore. 21 The coordinator appears to be giving leadership to 22 the pro,7ram. lie appears to be relating Y,,e.L.L to the 23 representatives from the tw6 medical schools, and he appears to 0 24 be communicating with RAG. lioNNever, as we had an opportunity kce-Federal Repottets, inc. 251 to discuss the activities of RAG with the members who were 180 I invited to the mectin-, it was our impression that RAG took 2 their direction from the coordinator, and although they were 3 information of day to day operations, that possibly RAG 4 was not as strong as it needed to be in order to fulfill its 5 role. Also RAG meets once a month, and does not have an ,@6 executive committee and in discussing t e reasons why 7 they chose'to go this way in their organization it became 8 apparent that because most of the-representatives are from ..9 Baltimore that it is easy for them to meet this way, and 10 because there doesn't seem to be a well-developed program they 11 have not really experienced A need for an executive committee. 12 Approximately two-thirds of the core staff are full 1 3time, and there are only three vacancies, and Dr.,Pavrens 14 assured us that these three vacancies could be filled. 15 Many of the concerns raised about the core staff in 16 the past were predicated upon the fact that esSeDtially they 17 were part time, and Dr. Davrens has 9ODe a long way in 18 terms of changing this situation. 19 The site visitors are still unclear as to whether 20 in reality Dr. Davrens and his support staff are roviding p 21 leadership to the medical schools in terms of the Regional 22 Medical Pro-ram mission or if the medical-schoois are 23 dictating the direction to the Maryland Regional Medical 24 Program. @ce - Federal Reporters, Inc. 25 The grantee organization, as I mentioned be ore, is Johns Hopkins University School of Medicine, and it 2 appears to have a very positive relationship with the @laryland 3 Regional IEedical Proc-,ram and would seem to be providing 4 them with the type of support help that they need. 5 Dr. Ancrum is going to continue with the report. 6 DR. MAYER: Gladys. 7 DR. AI\TCRU.I.I.- As far as participation in the 8 Maryland Regional Medical Program, they do seem to have quite 9 a variety of organizations and other professions in the 10 Baltimore area especially participatin- in that program. 11 They had some of the visitors there from some of the projects 12 that ivere going on, also other interested citizens around 13 the'Baltiniore area. Also they were very helpful in helping 14 to got the Maryland Health Maintenance Committee started, 15 which is a group that is currently operating-- 16 DR. MAYER: Gladys, is that one wired down there 17 for sound? You were coming through fine, Gladys, until 18 we got the additional noise. 19 DR. ANCRUII: They did play an active role in 20 helpingto establish the MarylandIHealth Maintenance Committee, 21 which is currently operating a health center in one of the 22 underprivileged areas in Baltimore. They do utilize some 23 of the community practitioners and also other community aides 0 24 for operating this facility. kce-Fedetal Repoiteis, Inc. 25 Also Sister said earlier most of the planning for 182 the area has been-I.ocall-y a!id throughout the Baltimore area. 2 The one way they seem to be moving away from 3 Baltimore is through the @lanpower Development and Continuing 4 Communication under Dr. Herl:)ert's leadership. 5 Also thev (lo have plans for correcting some of this and becoming more active in subregionalization by 7 involvin- the comprehensive health planning B a-ency. cx r> 8 There was a question among the site visitors about 9 how they were using the assessment of re-ionai resources. 10 The Epidemiological and Statistical Center did collect a 11 lar-e amount of data, but we vieren't able to determine as to 12 how did they utilize this data in determining needs, and also 13 using this as a baseline for developing some of their 14 programs. 15 In-the management they seem-to be emphasizing quite 16 a bit of strategy for developing health maintenance 17 organization. Both schools that are connected 'with the 18 program are doing further work in getting the health 19 maintenance organization established. 20 Also during the course of the site visit it was 21 learned about community activities that are being carried 22 out through the Division of Health Nlanpower and Continuing 23 Communication, and which they referred back to community 0 24 activities that went on with their second Monday series @ce-Fedetat Reportets, Inc. 25 several times throughout their presentation. i83 Also the way that these are monitored, they do 2 have quarterly reports which include.a summary of their 3 overall accomplishments and their fiscal situation. 4 As also stated earlier, the main center for 5 conducting the evaluation of all the projects funded.by 6 the Regional Medical Program for this area is the 7 Epidemiological and Statistical Center. In addition to look- 8 ing at the project for ongoing evaluation they also havea 9 committee that reviews the proposals and helps with being 10 sure that they do have quantitative ... that can measure 11 evaluation in the regional proposal. 12 Dr. Davens did state that this would be the, main 13 intelligence center for the Maryland Regional Medical 14 program, and that was also now a part of the core staff 15 rather than being a separate entity, Ilowever, we were not 16 clear as to how much direction for the center came from 17 Dr. Davens or they were still operating more or less as a 18 separate entity. 19 They have also worked out a conceptual strategy 20 for evaluating ail the programs, and they do have five 21 steps that they follow. These are determine the project 22 goals, determine the pro4ect objectives, determine the i 23 measurement of objectives attained, and also establish 24 standar and collection of the data on performance, and kce-Federal Repotters, Inc. 25 comparison of actual performance with standards previously set 184 Also there was a request for budffet for the 0 Epideiniolo-ical and Statistical Center in which th ey asked,for 2 3 additional fundin- for carrying out these activities and, 4 evaluating the project. I won't go into detail on that 5 now because Sister will go back and give you a summary of the 6 budget outline. 7 The program proposals that the program have, as 8 Sister pointed out, they do seem,to be leaning quite 9 heavily on the national goals that were sent ou in the new 10 mission statement. 11 In view of the major thrust in the new areas of 12 the health maintenance organization it is believe that the 13 proposed efforts would strengthen the service i n the 14 underprivileged areas. 15 I did mention about the one point that they have 16 going with the health maintenance organization. They also 17 had another in Columbia, I believe it is, the Johns Hopkins 18 school. 19 Under the area of continuing education, here is wher3 20 they are doing quite a bit of work in trying to get into 21 other regions other than Baltimore, and one of the reasons 22 that was given for this was with schools there and with the 23 ease that people get into Baltimore they felt they should 24 put their effort in the other area. ,-e-Fedetal Reportets, Inc. 25 Also they have a home care program which is 185 designed to give comprehensive home care to families. And also with the school of nursing at the Univerc3ity of 2 3 Maryland they are currently starting preparation for family 4 nurse practitions. The site visit team felt that the activities that 5 6' the program had projected for the coming year were realistic. 7 However, one thing that they felt could have been improved 8 was that the medical schools could hw e made a substantial 9 contribution to areas other than just in the Health 10 Maintenance Organization. 11 In dissemination of knowledge we were assured that 1 2 wider groups and institutions would receive immediate 13 benefits from the activities that were planned and also 14 those ongoing. However, it wa,,3difficult to pinpoint what 15 available benefit the information would provide groups in the 16 outer area. 17 One of the other projects, too, is they are starting an information center in which the Re-ional @-ledical 18 19 Program will be employing some of the core staff, and it 20 will be more of a survey type of questionnaire in which 21 they Nvi.11 be getting information from insurance companies 22 and others about people who come in for the treatment 23 of drugs. 24 Do -you want to add anythin-? Fedetat Repottets, Inc. 25 SISTRR ANN JOSEPIIINE-. The questions that werentt 186 I ans@%,ered to the site visitors' satisfaction really were the 2 follo@,ing: we couldn't seem to find out through what 3 mechanisms the goals, objectives and priorities were 4 developed and approved other than that they were a response 5 to the new direction from the Regional Medical Program. 6 Also there was some concern that most of the proposed 7 activities to be carried out over the next three years will 8 be geographically located in Baltimore, and that roughtly 9 25 percent of the requested budget is going for HMO activities, 10 and it was unclear again on what basis-this decision 11 was made other than again in response to legislation and 12 existing activity that had been going on. 13 Vle were unsure about the nature of the region's 14 planning process and at what point in the development of 15 a project evaluation is built in. 16 Also Nye were not clear about the.nature of the 17 strategy and methodology used for carrying out project 18 evaluation, nor was it entirely clear who carries out project 19 evaluation, project staff or center staff. There was 20 indication that this is presently being worked out, but that 21 in many instances it was not applied to the projects in the 2 2 proposal that were submitted for triennial support, Also - 23 we were not clear as to how the results of evaluation 24 activities affect the region's decisioiimdking process. ce - Federal Repor tefs, Inc. 25 And for these reasons we thought it 'wise to i87 I recommend that the triennial application not be approved 2 as the triennial application, but rather approved for two 3 years at a direct cost support level of $1,294,960. And 4 originally the proposal was to approve it at a level of 5 $1,325,000, but in the recent mail a communication came from 6 Washington stating that the recommendations of the 7 Mini-Sarp review on the anti-lymphocyte globulin for renal 8 allograph project number 43 be deferred pending national 9 RIIP policy on funding ALrs production. 10 We are recommending that the developmental component 11 not be supported, and we are recommending that the project 12 level of $861,313 be reduced to $7i4pOO4. And the areas 13 in which we are making reduction are in the areas 'O'f the 14 HeaJ-th Maintenance Organization proposal submitted by the 15 University of Maryland Medical School contract for $172,309. 16 Dr. Farrell -- is Dr. Farrell here? Dr. Farrel 17 was present on the site visit team, and it was his 18 recommendation, and the group concurred, that since the other 19 organization that is supporting ILMO activities will provide 20 $25 000 for a feasibility study and he felt that since the .21 description of this project made it fall essentially into 22 the category of a feasibility study that to fund this 23 project at a $25,000 level would be appropriate. 24 Also it was the decision of the site visit team ce-Fedefal Reporters, Inc. 25 that mini-contracts which had been used by this Regional 188 I Medical Pro-rem and were fUDcled at a level of $95,270 be CP 2 reduced to two and a half percent of the total funding, which 3 would bring this to $32,335. That two and a half percent 4 was arrived at after some discussion in the group. As 5 Dr. Daven explained the use of mini-contracts they really 6 were used somewhat like developmental component money would 7 be used. If a person came and had an idea for a project 8 that would be short term or needed some matching funds then 9 mini-contracts were sublet. And he pointed out that these had 10 been attracting many people to the Regional Medical Program, I 1 but it was also pointed out that many people would be 12 attracted to any program that had money to give 'out. 'So that 13 possibly this might become a slush fund unless it were 14 controlled in a different v.,ay. 15 On page i9 of the Mar y.Laiid-Regional Medical 16 Program site visit that,is included in your folder are the 17 site visit team recommendations, and members of the staff and 18 Dr. Ancrum and I would be glad to answer any questions on 19 these that you have to ask. 20 DR. MAYER: That final figure instead of 21 a million 325 was what, Sister? 22 SISTER ANN JOSEPHINE: A million 294, 960 for two 23 years, at the end of which time they could resubmit their 24 triennial application. And the reason that we asked for two .C(I-Fedefat Repoiters, Inc. 25 years rather than one, we felt that it would make it possible 189 for them to develop an application that could show that they 2 were able to evaluate the new direction which they had 3 00 suddenly taken with their program. 4 DR. MAYER: If what I interpreted was correct-they 5 are currently operating at a million 672 level. 6 SISTER ANN JOSEPHIh'E: Yes. 7 DR. IIAYER: This in effect then is a reduction 8 of almost 300,000,$280,000 over their current operating 9 level. The interesting thing to me was it still provides 10 them with about -- if I am reading the yellow sheets correctly, 11 with a little over 550,000 more than they have in carryover, 12 which means that they must be phasing out a tremendous amount 13 of effort, $900,000 worth of effort this year, if,l aTn 14 reading those yellow sheets correctly. Is that correct? Are 15 they phasing that much out? 16 On one hand it says that the activity this year 17 is at a million 672 in the 03 year, and then on t.he other 18 hand it shows for the 04 program continuation with approved 19 period of support, and continuation beyond shows only 20 74itOOO, which suggests to me that they phased out about 21 $600,000 somewhere. 22 DR. @TCRIIII: I think they phased it out during 23 the time there was a reduction in the funds, they had a 0 24 25 percent cut and they phased out sone of.the program. They @ce-Federal Reporters, Inc. 25 used the amount that was in the ongoing program. 190 I DR. @IAYER: I guess the point is that they have got 2 a million six now in operation, aud it only shows -- well, 741 3 of continuation of current activities of the 03 year into 4 the 04 year even in their request, unless I am missing 5 something. 6 VOICE: You are right, Dr. Mayer. They have about 7 eight or Dine projects that come into the end of the 03 8 year support period. The sheet you are looking at, the 9 only activity they have ODgoing in their request is number 10 19 and number 27 and project number 35 which are in this 11 summary which all of you have a copy of. Anything else, all 12 their work in the area of stroke, coronary care units, are 13 all coming to an end. That's what Sister Ann referred to 14 a minute ago when she said they had done a 180 degree turn- 15 around in the program. 16 DR. MAYER: So that on the one hand although it's 17 a reduction of current operating activity it's an increase '18 in terms of dollars togo into new program. That's the only 19 point I am trying to make. 20 All right, other comments? 21 Yes, Jerry. 22 DR. BESSON: Sister, I'm not sure that t understand 23 the relationship between the-proposed inini-contracts where 24 40 they request $95,000 and how they expect to use this money @re-Fedefat F@epotteis, Inc. 25 other than their developmental component. As I read.the application I gather that they want to be able to respond thrusts 2 quickly to changes in R@IP mission and evolving new 3 in national health programs, and this is really a description 4 of what the development component is. And yet you suggest 5 that the developmental component not be funded, but that 6, the mini-contract be funded in part. 7 SISTER ANN JOSEPHINE: lVell,, I agree with you on 8 that. The mini-contracts as we heard them described -- and 9 we asked several times -- were described in such.a way that 10 they could be describing the developmental component. it 11 was the thinking of the group that rather than eliminate that 12 entire amount we would reduce it this time, with the 13 recommendation that it not be supported at a future date. 14 But there really wasn't other rationale behind it. 15 DR, BESSON: And the other question I have relates 16 to the $25,000 that is recommended for project number 37, 17 the IP.10Ihealth care study. Again as I read this University 18 of Maryland IPlo proposal I wonder whether the admonition 19 that Dr. Margulies mentioned this morning about R@-Ugrole in 20 HNIO's being eliminated to foii ow the assessment of 21 manpoger utilization and emergency medical services, whether 22 what they propose to do with this IL@10 health care study doesn't 23 lie beyond the scope of that. They are really asking for 24 funds to develop an HMO for a particular area, and.that would., 'ce-Fedetat Repofters, Inc. 25 clearly'lie beyond the purview of R@IPS purposes, and so I 192 I am wondering why even this 25,000 is-- 2 SISTER ANN JOSEP]II.@YE: I)r. Bessoii, there were 3 members of the site visit team who raised the same question 4 you are raising, and at that point we turned to Dr. Farrell 5 who was there representing the H,@io operation and asked im 6 if he would talk to this point. And he, as I remember 7 and other members of the staff may want to comment on this 8 he indicated that he felt this was within the purview of the 9 Regional Medical Pro-ram support. And I know at the time 10 this discussion went on there were those who raised the 11 question whether at a future date, since we do not have any 12 guidelines that enable us to mal@e these kinds of distinctions 13 at the present time except consultation we get from staff, 14 whether at a future date we are not going to have real 15 problems since the H!10 effort is being funded from two 16 separate pots, and say, you knovi how much of the RIIP money 17 should go into this. This question was raised, and 18 probably someone els e from staff wants to comment on this. 19 I would also share your concern. 20 IM. TOONT,,Y: Sister, I am confused, because on 21 page 21 of the -5ellow sheets you have got the ILIAO information - 22 system which is with Johns Hopkins, and then -you have a 23 contract with the HMO health care system at the University@of 24 Maryland, and I understood you to say that the one at @ce-Fedetal Repottets, Inc. 25 the University of Maryland you disallowed. 193 JOSEPIlliN'E-: This would be reduced from S IS TER A-1@N 2 172 thousand to 25. 3 MR. TOO@IEY: How about the one at Johns Hopkins? 4 SISTER ANN JOSEPHINE: Well, the one at Johns 5 Hopkins -- and again we relied on Dr. Farrell as we were 6 makin- this decision -- the one at Johns Hopkins was allowed co 7 for the amount that they requested, Apparently the 8 center at Johns Hopkins University is already participating 9 or providing data for the national effort in evaluating 10 Health Maintenance organizations-- 11 MR. TOO?,IEY: Is that the East Baltimore-- 12 SISTER ANN JCSEPHII\TE, :I think Dr. Farrell felt 13 that if this ,Yere disallowed that it might interfere with 14 this other effort, and I think this whole thing I'm glad 15 this came up because I think this whole HMO discussion needs 16 whatever clarification can possibly be given here from staff. 17 MR. TOOIEY: And then -you have another University 18 of Maryland, the Bon Secours Comprehensive Health Center 19 is involved with the home care program. 20 SISTER ANN JOSEPHI,NE: Yes, and that home care 21 program is under this health education. 22 @M. TOOMEY: It just would seem to me that 'What they 23 were doing is trying in a way to split the derivation of 24 information between the single efforts of the two ,ce-Fedefat Repoiteis, Inc. 25 universities to provide health services through these HMO'S. 194 S ISTER ANN JOSEPHI,\T,: Yest we shared your concern. 2 IM. TOO,@iE@Y: Actually,one of them could probably 3 have taken the whole ball of wax. 4 DR. THUR',IAAN: Could we carry that just one step 5 further because on the top of 23 there is another $84,000 6 for Ht.10's which looks like it's really the E&S center. 7 The two on 21 that Dr. Toomey has referred to and on the 8 top of 23 is another $84,000 for Mli'ols, and how much of core 9 really goes to E&-S? I guess that's the real question, 10 because it really does look like all three of these contracts, 11 and the fourth one, too, would go back to MS, which is going 1 2to make it a pretty expensive operation. 13 MR. TOO!,T,,Y: May I ask is this Maryland Health 14 Maintenance Committee incorporated? Is that the Columbia, 15 Maryland-- 16 SISTER ANN JOSEPHIb7E: No. No. 17 NUt. TOO@'M@ Y: Vlell, did you mention that they were 18 involved in that? 1 9 SISTER ANN JOSEPHIb7E: Not I didn't. This 20 corporation is one that Dr. Da ven has been working with and 21 has been interested in. 22 DR. THURMAN: They also have another contract from 23 another-- 24 SISTER ANN JOSEPIIINIR: That's right. -The whole kcf,- Federal Reportets, Inc. 25 IIMO are ahere is very muddy, and this Aas_ the reason I think 195 Dr. Farrell was provided from staff. This never was really made clear', and then today after Dr. I.Targulies' remarks 2 3 I felt a little more unsure about this because I was prepared 4 to come in and say that I felt that since there was another 5 organization that was providing support for the development 6 of li?,IO concepts the question I would raise is how much 7 money should be supplied from Regional IIedical Programs. But 8 if I heard the discussion this morning I think that this is 9 not a part of the consideration. Is that right? Which is 10 a little confusing to me. I I MR. CiliL%IBLISS: I would think so, if I might just 12 answer a bit here. It is my understanding that the limited 13 amount, not to exceed $25,000,, might be used for planninc, 14 and development for the feasibility aspects of the HI,10, 15 that the larger amounts have to do directly with the 16 actuarial side, the marketing, the packaging, the establishment 17 of an IIMO and the funding of it,.the front funds required 18 to got it going. And that is not within the province of 19 RtfPS. But certainly as it relates to planning of the 20 initial feasibiliIt-y and the monitoring of the quality of @21 service rendered therein those are two aspects which 22 Regional Medical Programs could be involved with its funds. 23 DR. ?,!AYER: Would you like to corament? 0 24 MR. HINKU,: Yes, Dr. Thurman made reference to ce-Fedetal Reporters, Inc. 25 the Ela They are supported by total budget of 179 or 189 19G art of 1 thousand dollars. Nolv with reference to the HMO p 2 $84p7OOp that is in conjunction with a contract the Hilo 3 office has made with Maryland Health Maintenance Committee 4 in @laryland, and the R,@IP of Maryland decided -- they 5 obligated themselves to take on the responsibility of setting 6 up an evaluation mechanism for this Maryland Health 7 Maintenance organization committee up there, and that is 8 to set up an HMO other than the one they have ongoing now. 9 They have one through Johns Hopkins and this other one. And 10 they are going to try to set up an evaluation mechanism for 11 this Maryland Health Maintenance Committee HMO activity 12 which is slippor-tedabout $250,000, and they are going-to set 13 up a system within Baltimore that can be later on,,expanded 14 throughout the state of Maryland. 15 And repeatedly -- and Ithink it was mentioned 16 an't the before here -- we asked the same question, why c 17 EVIS center set up this mechanism, and they repeatedly 18 advised us that they are overworked now, they don't have 19 sufficient staff to take on this additional responsibility. 20 So that's the reason they have a separate project 21 in here to go out and get outside assistance in this 22 evaluation. 23 DR. THURMAN-. It says will also be part of the new 0 24 activity of the E&B center core staff. So tliat-'s not ,ce-Fedefal Repottefs, Inc. 25 outside. 197 @M. HINKLE: -I was speaking about the $84,700. 2 DR. 71[UR@IP2@: So was I.. The last statement under 3 the 84,000 one is "will also be part of the activity of the 4 .@E&S center core staff." 5 IM. HINKLE: But this 84,000 is to go outside and 6 get theessistance to set it up, and the E&S center has their 7 hand in everythin-going on up there, and they are also going 8 to help in there. But they dont pinpoint how much of their 9 $187,000 will supplement the 84,700. 10 DR. MAYER: lVell, what that said to me, Bill, was 11 the E,@IS center was goin- to carry out an evaluation of that 12 contracted outside evaluation system. Now is that what they 13 are planning on doing? 14 MR. HINIUX, No-- 15 DR.- ITAYER: They are going to do it? 16 IM. HINKLE: They are going to assist in it. They 17 are going outside to get help to do it because their .18 staff, their overworked status up there which they kept I 9 referring to, it doesn't have enough people to do it on 20 their own. 21 DR. MAYER: But they are going to keep close tabs 22 on it. They are going to subcontract some part of it. 23 tgt. HIHTKLE: In readin- the project anything that tx 24 has to do with the mission they say EV@ center is going to have -Federal Repoitets, Inc. 25 a hand in it also. There is.a survey which they are going 198 I to conduct with outside funds, which is another project, and we asl@d them why can't the E&-S center conduct this. 2 3 There again they said they are overworked with available 4 staff and they don't want to get out and hire additional 5 people. 6 SISTER ANN JOSEPHINE: I got the impression, too, 7 that the E&S center is already -- someone has contracted 8 with the EgzS center to provide some of this data collection 9 and evaluation, and are presently engaged in it. l'O tM. HINKLE: This point is another aspect that the 11 site visit kept focusing on, the site visitors wanting to know 12 why the E&,S center is doing so much outside evaluation v:ork 13 for other people, why can't'they get these people to pay for 14 it. And they finally in the final analysis said they have 15 been thinking along those lines and they plan to do it, have 16 the E&-S center contract outside. 17 Now on one hand they say their staff is overworked 18 and they can't do it themselves, and on the other hand they 19 say they are doing work-for people outside. This is just 2-0 one of the ambiguities we kept running into every time we would 21 ask questions. 22 DR. MAYER: Dr. Farrell, one of the questions that 23 has been raised was whols on first in the HMO situation as 24 it related to,the Maryland project, and with some lack of @ce-Fedeial Repotteis, Inc. 25 clarity of that, and we wondered if you could comment about it. I DR. FARRELL: Yes. This is the University of 2Maryland? 3 DR. MAYER: Right. 4 DR. FARRELL: My reading of that was that it was 5 what was the word we used -- marathon evaluation project 6 to the extent if an HMO were started in-the community 7what would be its effect upon present provider structure 8 and particularly upon the state run medical school. Most 9 of the planning contracts of the 11,MO service are to the 10 extent of $25,000 limit, and this was three years for something 11 in the range of $1870000 a year, if I remember it. 12 DR. THURIAAN: Why was there a difference between the 13 'University of Maryland and Johns Hopkins? That was the other 14 question. Johns Hopkins is 146. That's a big difference. 15 DR. FARRELL: Well, they are dealing with an 16 operational HMO, and they are.doing a specific quality care 17 project. 18 DR. KRAWLEIIISKI: Were -you able to determine how 19 many other granting agencies were involved in these HMO activitie 20 in these schools and whetber.this-logically fits in with 21 their funding so it makes a pattern? 22 DR. FARRELL-. Yes, the only HMO service is from the 23 HMO,s now. 24 DR. KRAWLEIYSKI: Do they have a grant from an 'ce-Fedelat Reporteisi Inc. 25 insurance company also? zuu RELL: The Columbia project 'You mean? DR. FAR 2 DR.,KRAWLEIYSKI: Right. 3 IM. Tool;liEl Y: Nov the East Baltimore project. The 4East Baltimore project has somewhere in the neighborhood of 515 to 20 federal programs participating in that. I don't 6know whether you call it an H@io at the moment, but in actual 7practice-- 8 DR. KRAI@WSKI: And the national center has some 9money in that in an evaluation form? 10 DR. FARRELL: There are all the specific aspects, ant , 11 Of course, it is one of these organizations that's eln,-, 12 looked at from about twelve different angles. it is not 13 typical. 14 DR. BESSON: Mr. Chairman, I think we are really 15 talkin- about something that Nye will hear many more times 16 1 for us before we see the end of HMO'S, and it will be wel 17 to make sure that we have a clear statement from the Council 18 and suggest what R@T Is bag is going to be in HMO. I heard 19 Mr. Chambliss say that one of the reasons we are fundina 20 project 36 perhaps or why we are giving this 25,000 is to 21 al uruls study feasibility, and as I read at least our loc 9 Am 22 interpretation of what H!,Iols relationship to R,@IP should be. 23 it's not for feasibility. That should be the H@10 organizations 24 in IISIIMA. kce-Fedetal Repoiters, Inc. 25 I think that this being the bottomless pit that it 201 I is, feasibility studies, developmental studies, et cetera, 2 requested from RIAP can really get us,far afield. Now 3 as I read the abstracts and then go back to the original 4 proposal I am not sure I read the same words that have been 5 reiterated here about why one project is going to be funded 6 and another is not. The entire project summary appears in 7 no greater detail than this yellow sheet does except by a sligl-,t 8 amount. And therefore we are left with just a series of 9 cliclies., some of which are okay words, and some of which are 10 not. But as I look at project number 36 which we are 12 suggesting may be funded, I see some okay words like routine 13 monitoring of the volume and ty@s of medical services, but 14 1 see some non-okay words like providing a necessary 15 financial billing functions and summary revenue statements 16 for accounting purposes, data for meeting the reporting 17 requirements of various external.administrative agencies, 18 actuarial useful data for estimating future utilization of co- 19 payment revenues and capitation costs. These are clearly 20 not within RIIPS purview. 21 -So I am not sure whether there isn't a little bit of 22 misemphasis in using some words that will again push the 23 tutton that gets the green pellet. And we went through this wi I 24 cardiopulmonary rescussitation a few years ago and cardiac Ace -Federal Reporters, Inc. .25 care unit, and if they said those magic words, bang went the 202 dollars. And I am a little bit afraid that this is what we So maybe at this earl are beginning to see with H,'.10's. y 2 3 stage of the game we should get avery explicit statement 4 from Council as to just wh at R14P's bag is in relation to HMO'S. And I would so move, couched in more elegant langua-c. 5 6 DR. MAYER: All right. 7 DR. BESSON: We have a motion on the floor, Mr. 8 Chairman, I wonder whether with all this discussion Sister 9 is inclined to modify any of the recommendations or-- 10 DR. MAYER: Well, I think, you know, the intent 11 1 gather the intent -- let me try to summarize what I pick 12 up now from what has been said. That what you were sayin- r> 13 Sister., was a deletion of the project component by,,about 14 $l5OpOOO, the basis of which was really deletion of that from 15 project 37, the University of Maryland II!,10, with the 16 provision of about $25 000 in that project for the effort p 17 as.it relates to the planning for,H,@110 activity. Is that 18 correct? 19 SISTER ANN JOSEPlilNE: Yes. 20 DR. MAYER: And secondly, -you therefore were saying 21 full funding of project 36. And Jeery just raised the 22 question whether items 2 and 3 under the objectives of 23 that project were appropriate. I think we can handle within 0 24 the motion-that was made by saying that we' would-recommend ice - Federal Reporters, Inc. 25 that level of funding, but would request that Council review 203 I both of those two issues vis-a-vis the reduction of that by 2 either 25,000 more, if thatts inappropriate or by reduction 3 of it even further by whatever is.repre,sented in dollars 4 by components or objectives 2 and 3 of project 36. And if 5 we red flag that and ask that then I think we have handled 6 both the dollar component as well as those two issues. 7 DR. BESSON: If we also add to-- that, Dr. Thurman's 8 concern about project 41, and Mr. Toomey's concern about 9 project number 40, is it? 10 SISTER ANN JOSEPHINE: 40. 11 DR. BESSON: 40 for 30,900. These four pro-rams 12 that impinge on the ln,10'swe should have a policy decision 13 ma'be focused on these four projects. y 14 MISS A-NDERSON: Do you think we will have a chance 15 to talk about that tomorrow morning.maybe? 16 DR. BESSON: Yes, except that even though we are 17 not in executive session I constantly a,,n running against the 18 query that I ask myself as to where policymaking decisions 19 lie. I prefer to ask Council for decisions'. 20 SISTrzR ANN JOSEPHINE: I would like to say that 21 the questions that are being raised here are the questions 22 that continued to disturb the site visitors all during 23 the site viist. And as we had our discussion this morning 24 I just 'thou-lit to myself Maryland is going to be just a De@Fedeial Reporters, Inc. 25 deiiiodstration project for the dilemma in which we found 204 We had I ourselves this morning. We really had no answers. 2 no guidelines. And staff was very helpful, but there just 3 were no guidelines to provide us. And we continue to be 4 disturbed, that here was e. pro-rwn that had taken an entirely 5 new turn and was in direct response to the most recent 6- directives from Washington, end that if certain components, 7 major components were deleted there would be no program. 8 IM. TOONIEY: Sister, can I take a crack at that? 9 It would seem to be that Baltimore, Johns Hopkins and the 10 University of ',%aryland are doing so much in so many areas 11 it doesn't make any difference where they get their support 12 -or for what they get their support, they are going to need 13 some support for everything. And if the m@-ic words from 14 heart disease, cancer, stroke, kidney and Washington were 15 so on, they would go in that direction. If it was health 16 maintenance organization or new forms of delivery of health 17 services they would go in that direction; and if they went 18 in that direction they have got two universities and an R,@.IP 19 and they decide that somewhere along the line they could 20 divide the money up. They are dividin- rho projects up. 21 D'R. KRAWLEIVSKI: With applications off the shelf 22 probably. 23 LIR. TOONIEY: Well, you know, they are doing all 24 these things and they need money, so where do you want o ce -Federal Rep6ftets, Inc. 25 at, and they don't really care. give it to them, for wli 205 1 DR, BESSON: lYel.1, there is one other aspect of 2 this that I think is pertinent to put it 'historically, at 3 least focusing on @faryland's move in the direction of new 4 mission, and that is that a statement about their involvement, 5 in health maintenance ort-anization reflects back to the 6 RMP coordinators meeting in @larch, 197i following the 7 president's health message, and after discussion with 8 Secretary Richardson about the new mission for RTIP in IBIO'S, 9 and the words they use is thatfolloyring presentation the 10 following montN promotion of the development of IL@10ts 11 was featured as a prime activity for RTilPIs because of their 12 experience and their close relation to the provders of 13 health care." 14 That was before there was an HMO office -yet 15 created. Now there is one, and now,the turf is being a 16 little more carefully delineated and R.@IP no longer has this 17 large potential char-e, but a more refined charge o 18 assessment of quality of care in HNIO'S. 19 Now if that's going to be our focus I would like 20 Council to state that explicitly so that we can be sure that 21 our funds aren't lost in the morass of funding development 22 of IUiO's. 23 DR. MAYER: Is everyone clear on the questions 24 being raised? The questions are being raised relative to, ce - Fedetat Reportefs, Inc. 25 as I previously stated -- relative to number 36 and number 37 206 I in the frame of reference that I raised them, in the dollar 2 amounts that I raised th,3m, also are being raised in terms 3 of project 41 and the appropriateness of that. And I assume, 4 Mr. Toomey, that the question relative to project 40, which 5 if there wasn't any talk of Hilo's in here I don't think this group would have had any difficulty with, but I think 7 it is being raised in the framework -- at least let me 8 try it -- that your thought was that that is additional 9 information that may be useful to the formulation of an IUAO. 10 Is that the context in which you raised the question on 40? 1 1 MR. TOOMEY: Well, that's part of it. The other 121 part is that it is a statistical study, it's part of the 13 E&,S, could be part of an E&-S grant. My concern iq that they 14 have overlapped so much in separate projects. This project 15 40 with project -- one of the earlier projects. 16 DR. THURIIAN: Forty relates to 35. .17 MR. TOO!.IEY: Forty relates'to 35, and 36 and 37 18 are just two parts of the whole. And I think my han--up co 19 is that they have just divided them up. 20 DR. MAYER: Okay. Further comments? 21 DR. WHITE: Can I ask something that doesn't relate 22 to HMO'S, except peripherally perhaps? Sister, I was 23 on two previous sitevisits to Maryland, 1968 I think, and 24 I have forgotten when the other one was, and both of them kce - Federal Reporters, Inc. 25 seemed to be sort of in an area of opportunism, and the 207 I original one, heart, cancer and stroke was all the word, and 2 we had very elaborate stroke proposals, as I recall, 3 somethin- that had to do with congenital heart disease, and 4 one thing and another. The next time around, I have forgot 5 what the guidelines were at that particular time, but they' 6 responded to them also, some kind of elaborate project 7 mechanism which seemed to me it was a system of directors 8 of continuing education or something of that sort. nd 9 now perhaps we are seeing the same kind of response at this 10 time. 11 But then there is the theme.between here, and that 12 is the epidemiology and statistics function, and on each. 13 of those previous visits there was a question of what they were 14 doing, and we were told well, any moment now we are going to 15 have a real -basis upon which we can. desion bur own pro-ramis, 16 and yet now I hear again that we don't really have anything 17 from that, and that was a very sizeable budget item, as I 18 recall, in earlier years, and even now. 19 And on page 14 of your report at the top under 20 assessment of needs and resources this confuses me again 21 further. There is one statement about the site visitors were. 22 concerned that the overall needs assessment had not bee n 23 carried out. And yet on the last paragraph of page 8 it 24 seems'as though the statement there is a'little-bit ce-Federal Repotters, Inc. 25 contradictory, and I wonder if you can clarify that. I 208 wonder if you can help me got a gr@-p of the Regional 2 Medical Program general -- separate from whether or not this 3 parceling out of ILAIO money is appropriate or not. 4 SISTER ANN JOSEPIIIINTE: Welip I have never been to 5 Maryland before, but I was impressed that the guidelines 6 and the program as it was developed was an aspect of an 7 opportunistic response. 8 In discussing and thinkin- about the Epidemiologica 9 and Statistical Center it was my impression that although 10 in the past been funded under core staff this center had 11 it had in truth not really been an integral unit in core staff. 12 And I think that the attempt that is made at the pre-sent 13 time Iwith the appointment of a new director, Dr. Leon Gordis, 14 is to achieve the objective of having some of the effort 15 what percentage I wouldn't be able to determine -- but to 16 have some of the effort of this center provide the evaluation 17 and the planning types of services that they had spoken of as 18 being provided in the past. We could not identify that 19 this was being done at the present time. Everything that 20 was described was described in futuristic terms. 21 And I don't know whether that answers 'your question 22 And I don't know, maybe Harold would you want to comment 23 on that? 24 tM. O'FLAIMRTY: I think basically Nve-went there ,e-Fedeial Reporters, Inc. 25 with the concern that we could not reaiil( see the pay-off 209 I of the Epidemiology and Statistics Center. At least some of 2 us left there having that suspicion confirmed; that really 3 -we were unable to tell, A, was the center an integral part 4 of the program, and B, how had the results of its activities 5 affected the development and implementation and decision- 6,' making process of the Maryland Recrional @ledical Program, 7 In querying the chairman of the Rogional Adv sory 8 Group with respect to how decisions were made he informed 9 us that priorities, goals and objectives were set vis-a-vis gr(@u 10 discussion, and did not really utilize the process as 11 delineated for this center. 12 So we were concerned as a site visit team not only 13 with the effectiveness of the center and its output, but 14 also the Re-iona.L Advisory Group did not really appear to have 15 a logical reason dletre for decisionmaking. So these were 16 some of the reasons we went into questioning.really from 17 both ends the role of the center. 18 So to comment just one little bit further, the 19 RAG is so very- Baltimore based, and we felt that it was not 20 really reflective of the total geography of the region, 21 and we could not really see how it went about the business of 22 making Decisions other than throu-h the process of group 23 dynamics. 24 SISTER ILNN JOSEPHINE: I think it's fair to.say also, ,e- Federal Reporters, Inc. 25 that many of the site visit team when they left felt 210 somewhat uncomfortable about these recommendations but having no guidelines to make decisions about appropriation 2 3 of funds for health maintenance organizations it's very 4 difficult to deal with these kinds of problems. 5 DR. WHITE: fly concern is even if these proposals 6 were precisely relevant to whatever the guidelines might be 7 that I can see them as simply being something they weren't 8 really concerned about, but this was a way of getting some 9 money, and whether this represents the quality of the program 10 rather than the quality of the projects.that we should 11 be looking into. 12 SISTER ANN JOSEPIIIITE: Well, I think wherever there ).-a 13 any discussion it was very difficult to get a review of 14 anything that was being doir-or had been done. Everything was 15 described in terms of the future and how all these things 16 would fit in and then Dr. Daven kept coming back to the 17 point that they had the responsibility to form this network 18 of IMO's in the state of Maryland, and it was quite a 19 diversified group. 20 MR. OIFLAIMR7Y: One of the problems,l think, that 21 we see the 11).IO bag being fed to the medical schools as much 22 as it is, I think from a historical perspective that there 23 has been kind of a rift over there between the RMP and the 24 two medical schools, particularly with respect to who would kce -Federal Reporters, Inc. 25 receive the tissue typing project since there W,9-9 only one 211 1 tissue typing project given out, and it almost caused the 2 Battle of Armagetta. Nevertheless, what they did was 3 HMOts became a very popular mchcanism to have everybody involv@d 4 in, so instead of putting these people on contracts or 5 extension of core -- I'm sorry, on projects or extension of 6 core, they have developed contracts with these two medical 7 schools to be involved in the HMO area. 8 One of the things that we talked about in the 9 report was that we could not see an emerging conceptual 10 strategy for HMO's or the Maryland Pig)ls role. it was kind 11 Is. of a hit and miss approach to 11.@10 So the'172,000 that 12 went to Maryland was really just literally -- and some of 13 you on the team may disagree, but we talked about,this -- 14 appeared to be a mechanism for apneesing this medical school 15 since it didn't got one of the tissue typing projects. 16 DR. MAYER: Well, what's your pleasure? There is a 17 recommendation on the floor with modification already 18 incorporated in it. I think one of the messages that is cominil- 19 through to me loud and.-clear, which I assume is coming through 20 to staff, which I assume Would be translated to the Maryland 21 RMP, is that E&,S Center has got to become incorporated as 22 a useful device in ihe docisionmaking process of the Maryland 23 Regional Medical Program or it's going to be out-of business 24 at least as far as funding is concerned, @ce-Fedetat Repbrters, Inc. 25 Now what beyond that do -you want to put as 212 I stipulations o n the motion other than the ones we already 2 have? 3 DR. YffiI72: The motion is for one million two 4 nine something? 5 DR, IDAYER-. The notion is for one million 294 6 with the potentiality of further reduction as a result of 7 projects 35, 36, and 41, I think it was, and their relationship 8 to are they appropriate as funding under RMP due to 9 RMP's role in HIIO s. 10 MR. PARin: Sister, may I ask -you a question? SISTER ANN JOSEPHINTE: Yes. 12 LIR. PARKS: This concerns a couple of things. lVas 13 there any.feeling or concern among the site visit,,group 14 that this program being administered by two,rather large, 15 and certainly universities with rat.her wide reputations, that 16 they were missing or not reaching the rural population of 17 Niar@yland, and did you see any -- this doesn't come through 1 8 clear. There is some compromising language in several places 119 in this report. Do -yo-U see any manifestation of what is 20 categorized here as regiona.Lization? 21 As I go down this and go down the itemization here 22 I am almost at a point of wondering whether this program 23 really shouldn't be put on potice that some more substantial 24 critical changes be made within a time limitation, that only kce-Federai RePottets, Inc. 25 a conditional funding be given this program, and a short 213 I review of the progress. Was that at ail considered? 2 DR. MAYER: Wells I t,iiink that Was what I heard 3 by the intent of the motion to disapprove their triennial 4 request, their developmental component, and to say all right, 5 there are two years in which to meet some of these conditions 6 to come back for a valid triennial request. 7 SISTER ANN JOSEPHINE,: I'@e felt that by the time the 8 word got to them really they would have six months to pull 9 something together. Is that right? If we did it just one 10 year. And this could destroy a program. And this was the 11 reason why, and this poll was taken by phone, as we realized 12 the time limit set. Originally when we left Mar-yland.the 13 decision was we would make the recommendation that the 14 triennial application not be accepted, the developmental 15 component not be accepted, and then with the deletions 16 indicated, and also that they be funded for one year and 17 would have to re-apply and would.have to justify their 18 program; that by the time they got word and begin writing 19 it up act'uall@y they have about six months in which to do 20 this. And so in thinking it over the decision was that 21 possi61-y by saying two years, which is actually a year and a 22 half to work, that it might be a little more reasonable. 23 Now the concerns that -you expressed were expressed b 0 24 the group, and there were a number in the group.who went ce - Fedetal Repofters, Inc. 25 away very uncomfortable with this. I think there was question 214 about the regionalization effort. 2 In the discussion with.the people'who were there with 3 whom we could discuss this there was an indication that they 4 were beginning to move in this direction, the movement was 5 slow. And the majority of the members of RAG are still rom 6 Baltimore and are still heavily oriented toward the two 7 medical schools. That was a point of concern. 8 There was a young.doctor from a minority group who 9 was functioning with one of the programs who was very 10 articulate and very impressive and very involved, but whether 11 this represents a move toward Minority group needs was 12 difficult to evaluate. 13 MR. PARKS: The reason I asked about the outreaching 14 to the rural areas is that there is a considerable portion 15 of Maryland that is in fact rural, and that is where I would 16 imagine the vast number of people, aside from those few pockets 17 close in here, Tobbytown and some places like that, where the 18 underserved populations, especially minority populations which 19 are not served they are not underserved, they are not 20 served -- St. ?,Iary's County and various other places, where 21 they are not reache d. And this is why I asked whether you 22 got a feeli ng that there would be a kind of movement toward 23 reaching out further. 24 SISTER ANN JOSEPHINF,: I personally got the feeling tli!.t te-Fedefal Reportefs, Inc. 25 there was an effort being made to move out.in that direction 215 1 and probably sorp- small successes v,,ere being achieved. 2 MR. pAryg: was this one.of the programs, in light 3 of the information we got this morning, that was reduced or 4 affected at all by prior funding reductions? Do we know that? 5 DR. ANCRLUJ: I think this has been a problem for the 6 last two years, that most of their efforts have been concentrat d 7 in the Baltimore area with very little involvement of the 8 rural or the outer areas. 9 MR. PARKS: Right. This morning I heard that a 10 number of areas were affected a ye ar or so ago by reductions 11 in appropriations, and now that there is a surplus that has 12 developed or an increase in appropriation, the application 13 of them administratively would be first to those programs 14 that fell into A, B and C categories automatically in terms 15 of awarding certain kidds of funds. -If me are ;here putting-so,, ie 16 limitations on the program in-this particular review I think 17 also we oOffht to put an embargo on any added to it 18 administratively. 19 DR. MAYI,;R: Yes, Judy. 20 MRS. SILSBEE: Under the circumstances, Mr. Parks, 21 this region is just being reviewed, so the level that comes ip 22 out of Council will be what we are bound by. 23 MR. PARICS: This morning Dr. Margulies explained 24 that there was-- @ce-Fedefal Reporters, Inc. 25 MRS. SILSBEE: Only up to the approved level of 216 Council-- 2 @M. pARKS: Ililft sorry?. DR. IIAYER: Only up to the approved level of 3 Council action was the qualifying statement of the add-on 4 even in-the case of those that vycre reduced. 5 6 NM. PARKS: Do we.know that level? 7 DR. IIAYER: Well, this is what we are arriving at, 8 and what we have said as part of the motion was a million 294 9 plus possible further reduction dependent upon interpretation 10 of HMO. And that's a level that is about 300 to 400 thousand 11 below the level that they are currently functioning. 12 DR. KPAIYLXWSKI: Add-.on not withstanding. 13 DR. MAYER: llt'eli,-further comments on the notion? 14 lye will have -- just to remind you, we would have the 15 opportunity, of course, of the anniversary review even if this 16 is passed to get some feel for what kind of progress has been 17 made in this, and another opportunity to put that last six 18 months of shot into them in case they don't hear the message 19 very cleari-y this time. But I think the message that has 20 come here is pretty clear to me, and I assume it is pretty clea- 21 to staff, of some of the real problem areas that are there. 22 IIISS ANDERSON: I would like to hear it spelled out 23 more clearly more community involvement should be in regard 24 to these projects rather than a package deal by one person ,ce-Fedetal Repoitets, Inc. 25 or one organization. 217 DR. MAYER: Okay Further comments? SISTER ANN JOSE PH I 1,TE, I would like to make just 2 3 one other comment. I think that it applies to maybe a number 4 of Regional liedicai Programs, and that is that I think the 5 group needs to be very conscious of programs where there is 6 such a rapid turnover in coordinators, because this precludes 7 any kind of continuity of planiiin- and continuity of effort, 8 and it is really difficult to evaluate the progress made by a program. 9 10 DR. IslAYER: They need to provide a course like I 11 have tried to institute in my faculty on the care and nurture 12 of the dean and how important that is. They need one- for 13 coordinators. 14 MISS KE@RR: You are recommending not funding the 15 developmental component? 16 SISTER &NN JOSEPHI'.NT,: That's right. 17 I.TPS. SIIBBEE: Does not. the committee have the 18 prerogative to ask to see this application after one year? 19 DR. TIAYI,;R: Yes, I would assume that we do, and I hat 20 hoped that that was picked up as the intent of my comment. 21 MRS. SILSBEE: It wasn't. 22 DR. @SAYER: All right. Do you hear us now? 23 SISTER ANN JOSEPHIHE: It seems to me if we could 24 work through some of the problems presented by this particular FedeFal Repof tets, Inc. 25 Regional I!,edical Program we would have the basis for other 218 decisions that would help us out. 2 tM. PARKS: Sister, may I ask you something else? 3 In terms of continuation of support did you find that there 4 was any involvement, technical assistance or other things 5 from other federal programs that might be supportive in some of the areas in which these programs &re weak? 7 SIST.CR ANN JOSEPHI.NE: Would you ask that again? CD 8 tM. PARKS: Yes. Did you find any -- someone 9 mentioned here that the universities programwide are work ng 10 a number of developmental areas, and that this apparently was 11 one of the areas in vihich they fi 21 thing on the federal level that is implicit in Mr. Parks' 22 remarks. I think it would aufrer well for the periphery if 23 the center can show some leadership in this regard rather 24 than protecting their very parochial inter(ets as they have ,ce-Fedeial Repoiters, tnc. 25 tended to do inthe past,.and probably %,e see evidence of doing now. 2 So I think it might be in order' for Lis as the 3 Review CoryLmittee to recommend to Council again that a clear 4 statement of a coornative effort at least as far as li@iols are 5 concerned, area health education centers, manpower 6 utilization -- a clear statement be made by Council as to 7 how RL,,MS efforts might best be coordinated with other 8 agencies that bear on these questions. 9 DR. MAYFR: Got it. 10 Other comments'? 11 Yes,, Joe. 12 DR, HESS: One further question. If I understand 13 the proposal, it is 1.294, possibly less, which may brin- 14 down to the neighborhood of 1.2. They are currently funded 15 at 1.6, 1.7. Is this cut in funding,.which is really .16 substantial over current levels, is this going to do any 17 real damage to the pro-ram? 18 DR. MAYER: They have already programmed in the 19 phasing out of about $800,000 worth of that anyway. As least 20 as I read the-- 21 DR. Hr-,SS: I would just like to hear from the 22 site visit team that indeed this is not going to do too 23 much violence. 24 SISTER A.NN JOSEPHINE: I got the impression -- and 6ce- edetal Repottets, Inc. 25 I would like some of the others who were-there to comment-- 222 I but I got the imp.ression so far as the project number 36 2 that this is a project -- the.things that are outlined here 3 would probably take place anyway, but at a much slower pace. 4 And I don't know how this relates to other projects. I 5 am not sure that this cut in funding would necessarily change @6 what they are planning to do. @laybe they couldn't move as 7 fast. But they are phasing out the projects that I would be 8 really concerned about to provide continuity in the total 9 program, and they are phasing those out themselves. 10 DR. MAYER: Further comments? 11 Everyone understand the motion? 12 All those in favor say "aye.,' 13 (Chorus of "ayes.") 14 Opposed? 15 (No response.) 16 All right, lot me suggest that we take about a 17 five minute break at the outside just to get up and stretch 18 and clear our heads. 19 (A recess was taken.) 20 DR. IIAYER.: Could we get started, please 21 Let me suggest that what I would like to try o 22 do, if we possibly can, is to get through Louisiana and 23 Greater Delaware Valley before we quit. That may take us 24 to 5:30, a quarter to 6:00, but I think if we dontt do that Federal Reporters, Inc. 25 the pressure tomorrow is-going to be too great. I DR. Tilt.MlIAN: Could we do Greater Delaware first? 2 DR. MAYER: I have no objection to that if 3 Dr. White and.llr. Parks do not. 4 DR. IYIIITE: Doesn't make an y difference to me. 5 DR. MAYER: Okay. Joe, -you Avant to give this 6 then on Greater Delaware Valley. 7 DR. HESS: All right. This site visit was made 8 in mid December and the members of the site visit team you 9 can read, I will not take time to do that. 10 This region is in its third operational -year and 11 submitted a triennial application for developmental component!; 12 requesting renewal of core-- 13 DR. LIAIRER: Would you s@alc up or use the 14 microphone? 15 DR. TEESS: The greater Delaware Valley region 16 includes the area around Philadelphia and portions of 17 Pennsylvania, reaching up in the area of Scranton and 18 Wi.Lkes-Barre, and parts of New Jersey, and all of the 19 state of Delaware. 20 The major educational institution that has been 21 involved in this region are the medical schools in the 22 city of Philadelphia. The grantee organization is the 23 University -City -Science Center, which is an organization formed 24 by in.stitutions of higher learning in the Philadelphia area, e,,,l Repoftets, Inc. 25 formed to accomplish cooperative scientific project mmo ii me e I investigations, and because this was a co ting ground 2 for other purposes it would mean an appropriate grantee 3 amency in order to get the Regional Ile dical Programs going 4 and provide the grantee type of support. This history has 5 also led to a rather unusual type of arrangement in.terms 6 of the overall region's directions, and I would call your 7 attention to the organizational diagram on page 13 of 8 the yellow summary in which on the lefthand side we see the 9 University Science Center as the grantee organization, and the 10 board of directors of this center shoN@,n in this diagram 11 in a sort of parallel fashion to the Regional Advisory 12 Group, certain areaivide committees which report to both, 13 an d then the executive director reports directly,to the 14 board of directors of the corporation. 15 All of the board of directors of the corporation 16 are on the Regional Advisory Group, and the chairman of the 17 RAG is on the board of directors. But it was clear to us 18 as we investigated the policy making, decisionmaking mechanism 19 within this region that the real power seems to be in the 20 board of directors, not in the RAG. And the board of 21 directors is rather heavily weighted with medical schoo 0 22 university type representatives, as well as Philadelphia 23 representatives, and this I think highlights at least one 24 of the important problems that we encountered. Ace-Fedetat Repoltets, Inc. 25 As far as the goals, objectives and priorities are 225 I concerned, the region has identified some broad goals which 2 are in keeping with current national RIIP goals, but have 3 not taken the additional steps of factoring these down 4 into ... and having any system on priorities. As we 5 inquired about priorities, decisions are made at the moment primarily on the basis of their narrative of the particular 7 project, and we don't have a yardstick against which to 8 measure projects as they come in. 9 As far as accomplishments and implementation are 10 concerned, the core staff has enjoyed some success with 11 its supported feasibility studies. They have acquired some 12 community profiles which have contributed to the development 13 of S:data base and this data is being used by other 14 agencies concerned with problems of health and health care. 15 This is not occuring on a truly regionwide basis. We 16 found this has been done to some extent in the city of 17 Philadelphia, and a rather good study had been done in the 18 northeast regiODWide which had resulted in some good 19 projects which seemed to be addressing themselves to the 20 diminishing supply of health manpower. But it seemed to be 21 very spotty and even nonexistent in some of these other areas. 22 We were favorably impressed with the activities re lat 23 to peer review continuing education and manpower problems, 24 at least in some of the areas. ,ce-Fedefal Repottets, Inc. 25 The region doe5 not have a formal policy on continued support for projects beyond the approved period, 2 and their application reflects this because there are 3 some projects for which support is requested the fourth and 4 fifth year and there still are no definite plans for phasing 5 out those that have been funded for that long. 6 On the issue of minority interests, they are 7 aware of this to some extent, and are directing their 8 efforts, at least from the medical school basis operation, 9 to try to assist with improving the health care of some of 10 the underserved people in the city of Philadelphia. But 11 as far as representation on the RAG and policymaking, 12 decisionmakidg level, we felt that this region has much room 13 for improvement. 14 1 will not go into great detail as far as the 15 individual activities of each of the medical schools are 16 concerned. But I should.poin.t out that they have divided 17 up the city of Philadelphia amongst the medical schools and' 18 one osteopathic sch ool, and they now have responsibility 19 for defined geographical areas in terms of working to improve 20 the health care in these specified areas, and this we felt 21 was a very constructive step in terms of being able to 22 organize and coordinate their efforts in this area, working a)i 23 helpin- to set up neighborhood health centers and other 24 type of health care activities. And they have.also had some tal Reporteis, Inc. 25 categorical projects in the areas of medical school I responsibility. 2 I might also itiention that sonic of the other areas 3 outside Philadelphia do seem to be givin- some attention 4 to this,, although a-ain we felt there was room for co 5 improvement. 6 The coordinator has been functioning in his position 7 for about four months, and we felt that we had to make some 8 allowance for his relative neWDeSS in this position although 9 he was a deputy coordinator prior to being appointed in this 10 capacity. -We do not feel that he has a.strong RAG to back him. 11 His major backing direction seems to come from the board of 12 directors. 13 There are several key st@ff vacancies wh@ ,ch 14 exist which go back prior to his appointment and which have 15 not as yet been filled, and these vacancies limit to a 16 considerable degree what he is able to do because of lack of 17 staff support. 18 Regarding the core staff, three of the five senior 19 level positions are presently vacant, and the fourth will 20 become vacant -- or I guess is vacant now, as of January 1. 21 These key vacancies are: the Associate Director for 22 Plannin- and Evaluation; the Assistant Directorfor 23 Communications and information;.and the Associate Director for 24 Pro-ram Development and Operation. The one which is now .31 Repoticts, Inc. 25 vacant in addition to those is the Associate Director for Continuin- Education and Nlanpo,.Yer. There is an acting 2 Associate Director for Program Devf-,,Iopinent and Operation on' 3 a part tirqe basis, but we do not feel that this is sufficient 4 for what is needed. 5 We had the feeling that the coordinator is not 6- pLrs uing recruitment of people to fill the key vacancies as 7 vigorously as he should. We were told that he was being very 8 cautious to make sure he got the right people, and while 9 we concurred with that we also felt a sense of urgency to 10 get these vacancies filled because of the obvious need for 11 this kind of assistance. 12 We felt that most of the key health interests end 13 institutions were represented on the RAG. HoNvever there 14 were notable deficiencies with respect to nursing and allied 15 health professions; and as I recall,. there was no real 16 direct Linkage of organized medicine to the RAG, although 17 there are a number of physicians on it. most of the public 18 representatives were bankers, colle-c presidents, et cetera, 19 rather than the consumer type, particularly from the lower 20 level of the socioeconomic scale. There are specifically 21 as far as minority representation is concerned only two 22 blacks on the 61 member RAG, and we found little evidence that 23 there was this level of consumer input into the shaping 24 of policy and program direction. 'al Repofteis, Inc. 25 We have already mentioned the relationship between the board of directors of ECS and the RAG. The RAG 2 chairman at least, and the chairman of the board of directors are fairly comfortable with their relationship, but we 3 4 question the broader context,whether or not they are as comfortable as they say in this situation. 5 6 As far as the grantee organization is concerned we 7 found no evidence that the UCSC is not providing adequate administrative and other support. lYe had members of the teein 8 9 specifically look at some of the 'budgetary reporting 10 procedures, and so forth, which had been questioned on earlier I I site visits, and they seemed to be satisfied that that end 12 of it was be ing taken care of satisfactorily. 13 The region's five medical schools have been deeply 14 involved in developing the RIIP from the beginning and still have a dominant influence, and our feeiin was that perhaps 15 9 16 it is time for the medical schools to become less dominant 17 and other forces become more dominant in giving direction 18 to the R,@IP in this region. 19 The GDVRIIP and CH.P seem to be working quite closely 20 together in developing local planning groups. The CHP 21 is less well developed in this region than is RMP, and as a qp 22 consequence the Ri@iP area coordinator seems to be providing 23 much of the leadership and direction in this area. But we 24 anticipate that CIIP will pick up the slack. But as far -Ce t,,l Reporters, Inc. 25 as R.IIP's responsibility is concerned they seem to be doing .6.3 v 1 what they can to cooperate. They have established a 2 mechanism for obtaining CHP review and comments on various 3 applications. 4 We found that there has been considerable data 5 gathering in the region by the medical schools. They do have @6 an epidemiologist consultant who has worked with the RI.,IP and 7 has performed some studies, but again this is still a 8 bit spotty, it is not a general thing, and we believe that 9 this is an area that could stand considerable strengthenin- 10 As far as management is concerned, we have mentioned 11 the organization as far as the medical school responsibility 12 in Philadelphia, They do have a coordinating committ-ee which 1 3is comprised of the Rll,.IP coordinat@-in each of the;medical 14 schools, Dr. Woliman, and others on the central core staff 15 who meet weekly and attempt to by this mechanism coordinate 16 activities to this extent. 1 7 The Associate Director for Community Affairs, 18 is the member of core staff who is responsible for working 19 with the area coordinators and providing liaison, and we felt 20 that perhaps there might be.some improved strengthening 21 and coordination between what is going on in core and some 22 of the region. 23 The absence of an evaluation person on the staff is' 24 perhaps one of the reasons for the rather poor evaluation, %ce-Federal Repoitets, Inc. 25 andin some instances almost totally lacking, of some of the I projects which we reviewed. 2 The region recently formed an evaluation committee 3 which met, and we reviewed the minutes of meetings of this 4 committee, and this committee very quickly identified 5 this deficiency and made some recommendations to the RAG concernin- this But it is doubtful that their recommendation 7 can be implemented until they get the evaluation person on 8 core staff. 9 As far as the program proposal is concerned, while 10 it may have anumber of merits we do not feel it has the 11 qualities based on a systematic assessment of their needs 12 and a system of defined priorities, and as a consequence 13 suffers from the deficiencies which are a naturai,,,trend of every 14 resulting therefrom. 15@ An- example, one project in which we felt this was 16 illustrated was a project of pediatric respiratory care 17 in which the project had been replicated in a number of 18 hospitals and they were planning to replicate it several 19 more times, and the people from the project were there and -20 we spoke with them, and %,e asked them -- they had been in 21 operation for three years, and we asked them what impact they 22 had had, if they had any indices of the effectiveness of their 23 pro.-rams and whether or not they really knew whether the 24 hospitals where they wanted to disseminate it really needed detal "otters, Inc. 25 the program, etc., and they had really no information, there I had been no evaluation. So it really was by dissemination by 2 popularity and salesmanship rather than by any very solid 3 basis of analysis, 4 As far as dissemination of knowledge is concerned, 5 one of the strong points in this R@IP is their teami education 6 program, part of which is related to peer review and to the 7 model of quality of care assessment developed by Dr. Brown, ani 8 which is one of the strong areas in this total pro-rani, and 9 medical schools are quite involved in this endeavor. And 10 on this particular score I think they are doing reasonably 11 well. 12 Up'until the present time most of the region's 13 efforts have been related to or directed to the medical 14 school complex, and as a consequence some of the outlying 15 areas have not been receiving as much attention and 16 consequent funding as might be appropriate if one looked at 17 this on a regionivide basis. 18 Some of these other areas I think we have already 19 touched on. I will not belabor them. 20 There is some effort at regionalization, They do 21 have area coordinators, and are attemptin- to strengthen these 22 areas; in this particular category they seem to be moving 23 in the appropriate direction. 24 have already As far as other funding is concerned,-l a,ce*e,al Repoiters, Inc. 25 mentioned that they do not have a good record of phasid-@ 233 I out and planning new funds to support R@IP initiated projects, 2 and they do not have a firm, strong policy in this area.. 3 Is Dr. Iiinman here? 4 hIFt. PETERSON: No, he is not. He had to go to 5 another meeting. 6 DR. I-EESS: There were some renal disease projects 7 which were a matter of particular concern, and Dr. Hinman was 8 a member of our site visit team and paid particular attention 9 to these. 10 There is not a well developed r.egional kidney 11 disease plan, although there are active transplantation and 12 dialysis efforts goin- on in the region. But the feeling was tt 13 this region as far as developing a %,,,ell thought oat, carefully 14 planned regional approach to management of kidney disease, C7 15 just had not achieved it yet, and this has consequences for 16 the recommendation that we will get to in a moment. 17 Another particular area that we looked.into was 18 action which is being pursued by various people in the state 19 of Delaware to form its own)MIP and secede from the Greater 20 Delaware Valley, and this I suppose has had its impetus 21 from a variety of sources, including the Governor and we qp 22 understand that he has had some conversations with people 23 here in Washington, and so an, and for various and sundry 24 reasons are thinking about trying to like all health related 'ce-Fedetal Repoiters, Inc. 25 activities in the state of Delaware into a health services I authority. So that there are many broader implications for 2 this. 3 We spoke specifically with Mr. Edgar Hare, the 4 area coordinator, end we asked Dr. Cannon to come down 5 from Wilniinmton to talk with us to see what the view of the 6- R',,.TP people was in this business and seentiat light they 7 could shed on this problem from the standpoint of R14P, and 8 we were told that there was a fair ainount of dissatisfaction 9 on the part of the RTIP group in Delaware, feeling that they 10 perhaps had not gotten a fair shake as.far as both funding 11 as well as participation in policy setting, decisionmaking, 12 et cetera; and as a result they were really rather 13 ambivalent about this secession movement, and the, could see 14 some things for it and some things against it. Some there' 15 contradicted their statement that they hadn't@received a 16 fair share of the funding, and felt that they really had. So 17 this was a point which was sort of up.for grabs, it was 18 not really clear, but it was evident that this was a bone of 19 contention and was contributing in some way to the 20 secession movement. 21 At the end of our site visit we had a feedback 22 session with Dr. Kellow, who is the chairman of the board 23 of directors, Dr. lVolf, the chairman of RAG, and Dr. Wolirsian, 24 the RMP coordinator, and expressed there frankly some of the tcleeal Repottets, Inc. 25 current concerns which the site visit team shared about the I program. We raised questions about the relationship between 2 the board of directors and tbe.RAG and the representativeness 3 of the board of directors of the regionwicle concerns, and 4 suggested that they reexamine that relationship and this whole 5 question, and see if perhaps they might have some other 6 thoughts about it. 7 The second recommendation which we made to them was 8 that they give high priority to filling the vacancies on 9 core staff,, because we ust don't see how this remion 10 can function very effectively with the shorta-e of key 11 personnel which they currently have. 12 We called attention to the recommendation of their 13 own evaluation committee made in the summer of .17J., and there 14 also was an ad hoc committee appointed to study a special 15 report prepared by the Arthur D. Little Company who 16 came in as consultants to pursue a management study or 17 organizational study of the region and really read back to 18 them the recommendations of this committee that they give 19 attention to setting goals, objectives and priorities of 20 the regional plan, precisely the same ideas that we came up 21 ather n e,,Ys with, and it was interesting that this came as r 22 to the people that we had discovered this and were feeding ba(l 23 to them information which -Aa,-. already currently available. 24 d-e from the reaction on th faces they were And I would ju e I RePotters, Inc. 25 probably going to go back and read those reports a little I more carefully to see what was in them. 2 We felt that when attention had been give n to the' 3 issues of the management from the RAG level, the setting 4 of goals, objectives and priorities, and when they took again 5 at their total regional situation they perhaps can address .6, themselves to this secession movement going on in Delaware. 7 In the view-of the site visit team this is not a necessary 8 thing, and from many standpoints would be an un esirable thing 9 to try to carve out a separate RIIP for 600,000 people when 10 really Philadelphia has many of the resources and they already 11 have established relationships betNveen Wilmington and some 12 medical schools in Philadelphia, and so on. So that it 13 seemed to us that this was still a repairable breach, 14 assuming that other more overriding considerations at the 15 Governor's level and elsewhere do not come in to intervene, 16 But just looking at it strictly from the RHIP 17 standpoint, in our minds this was, of the two options, trying 18 to beef up and more adequately attend to the Delaware problems, 19 it was preferable to secession and the creation of a new 20 region. 21 In conclusion, we felt that there were many 22 positive features of this Regional Medical program. It was 23 clear that the resources of medical schools and other 24 ial Repottets, Inc. irstitutions are actively involved in RMP activity and have 25 contributed much to what is going on there at the.present time. Some of the activities are be-inninf- to have a 2 favorable impact on manpower utilization, ambulatory care, and 3 health care delivery problems. Planning iD the inner city by 4 tfi6 medical schools appears to have real potential for the 5 future, and they are very much involved in this. 6 Subregionalization is under way and has potential for the 7 future as well as important benefits already apparent, 8 ly in the Northeast area' especial Kow that's the plus side 9 of the ledger, 10 On the minus side, in summary, we found the absence 11 of a well thought out regional plan. We have already 12 mentioned the board of directors and the RACT, the Lack of 13 minority representation, the high number of centraL core 14 vacancies, the inadequate evaluation, the under utilization 15 of avilable data in assessing needs, and the program's poor 16 record for phase out. 17 Now as a consequence the team felt that this region 18 was not ready for triennial status and felt that there is 19 a good deal of work that needed to be done yet, and our 20 recommendation was for one year funding at essentially the 21 current level of 1.9 million. 22 We did not feel that they were ready for a 23 developmental component. They are currently operating son@ethi,@ 24 close to $200,000 under their approved budgets so we felt that Fedetal Repot tets, Inc. 25 there was some flexibility within this figure of 1.9 for a I certain number of feasibility studies, so it wouldn't 2 seriously impair them. 3 We felt that whatever report goes back to them 4 should attempt to enforce the points that were made in the 5 feedback session. 6 We were not in f avor of the expansion of the 7 renal disease patient support project or the initiation of 8 the demonstration and evaluation of chronic hemodialysis, 9. and the proposal for the school of radiotherapeutic 10 technology was contrary to R,@IP policy. 11 So in essence it was for one -year funding at a level 12 of 1.9. 13 a;y. Bill, comments? DR. MAYER: Ok 14 DR. THURMAN: I'm Just less tactful and everything 15 else than Joe, so I will just add a few things. 16 I think there is very little relationship that we 17 could define between the RAG and-the grantee adenc,y. That's C> 18 a very nebulous thing. lYithout the board of directors 19 I don't think the RAG would know where the grantee agency was. 20 I would emphasize arrain how ineffectual the RAG 21 is as far-as geographic representation in particular, but 22 also in other areas that Joe has already brought out. 23 Any time you asked somebody on RAG what thier 24 functions were it was like talkin- to a machinei you got deal Reportets, Inc. 25 evaluation, project approval and advisory capacity back, but 239 I nobody could define what those were. So that that made it a 2 little difficult to see how they were really moving alon- 3 Pete Peterson pointed out that 60 percent of their 4 money went to three things, and has over the 'years 5 coronary care units, continuing education, and the 6 pediatric pulmonary disease that Joe mentioned. And none o 7 these really have been well thought out regionally, are 8 well planned or anything else. 9 The planning studies in reference to the core staff 10 and.the medical school units theoretically are being done by I 1the coordinating committee established between the core staff 12 and the medical units, but those are not broad based,' they 13 what, eaqh other don't %,ork well together, they don't know 14 are doing, and rather than initiate they respond, and 15 that's very much of a problem. 16 The physician who is vice chairman of the .RAG, who 17 happens to be from one of the outlyiiig.areas) didn't know 18 half of what was bein- said. He said that they were really 19 not truly involved. Hp happened to be from New Jersey, and 20 not Delaware. And he was a little bit upset. He straightened 21 out and supported everything before the day was over, but he 22 initially was kind of upset. .23 The area coordinators have been stretched very 24 thin. But a- Joe indicates, that's one of the more kce-Fedetal Repotters, Inc. 25 positive features of what they have, because if that were to I work then their regionalization vlou.Ld really go well. 2 They happen to have one good politician who is a regional 3 coordinator, and he is doing a superb job of getting lir, Flood 4 into the act and everybody else. But the rest of them are 5 just really getting off the ground. 6 There really doesn't appear, except for the business 7 of splitting up the city, which is idea, as Joe indicates 8 there doesn't appear to be any understanding between the 9 schools about the fact that they are all working toward an 10 somethin- to ever'bod-y. -y reail RLIP that means y The -y just 11 don't have priorities. And I can't emphasize any more than 12 Joe has how weak this core staff is, and they really just 13 are -- something has to be done to shape that group up 14 or else it will continue to be five or six littig@1,111pts 15 runnin- all@over the place under the framework of one R,@T. 16 Despite all. those things, I think there are some 17 strengths there, as Joe has indicated. But it would 1 8 appear to me that it was time to really draw a few lines for 19 them and make those lines reasonably definite. But I have 20 a lot less tact than Joe. 21 One other positive point, they have used a lot of 22 developmental component money by small subgrants to the 23 medical school units primarily to coordinate or to give.X 24 amount of dollars, and $75,000 they are-asking to get a kc tal Reportets, Inc. 25 project goin& which has been developmental component money, and they will pic-ic up money here, there, every place else. 2 But that has served a useful purpose as they have begun to' p ut 3 some guts into the core staff which they haven't had in the 4 past. 5 That's all I would add. 6 M . tiA@IE, R: Leonard. 7 DR. SCIERLIS: I guess in view of what they have 8 asked for you aren't being very generous, but at the same 9 time I tried to make some sense out of page 3 of the yellow 10 sheets. Perhaps you can help guide me. on that. Column 2,@ as I read this, a project which they will continue to 12 would be those which the initial support are really outside 13 period'.. coronary care, and as I turn over the sh@pt some 14 of the pulmonary, etc. In other r@ords, what will they 15 really be doing with that 1.9 million dollars? Are you 16 making 'your messa-e to them clear at this point, will they be 17 putting that money into the same. old projects, since you 18 have really told them they can't do som of the others they @19 would like to do, What will they be doing with that sum 20 of money that is any different than what they are doing nov.,? 21 I view them as having a couple hundred thousand 0 22 dollars thrown into the developmental components. If I 23 read it correctly -- well, that's why I need -your help in 24 defining how you are suggesting they spend that-money. ,c. - ..@,al Reportets, Inc. 25 hero are DR. HESS: These projects that you see I indeed ongoing projects, sone of them go longer than we@-would 2 Ordinarily like to see them go.. But at the same time I don-ft 3 think it is fair or reasonable to the people'on the other end 4 of the pipeline to suddenly have a cut-off, and the-y have 5 got to have some time to do some phasing out, preparing, and @6 so forth, in order to not do too much violence to what they 7 have already done. So our rationale was to give them a 8 year to do some re-thinking on the basis of this recommendation. 9 And I might also say that another point that isn't Watkins from-the Counci 10 written down here, but Drz. I raised 11 this point, and I certainly concur with it, that this reg ion 12 should have ongoing R,@LDS staff contact to help make sure that 13 the message is interpreted to them so'that if the-y.,choose to 14 come in in another year with a triennial application that they 15 indeed do the homework they need to do in order to be ready 16 for that. 17 But in fairness to the people in the communities who 18 are counting on this funding we just didn't feel it was 19 fair to them to try to cut that back too severely, and they 20 are attempting to move in the "new direction" of RMP. Their 21 ability to do that largely comes out of the core staff'and ip 22 some of the small feasibility studies that they can obtain, 23 and their general approach is consistent with the way they 24 @ce tal Repoitets, Inc. manage things in terms of the RAG,and the way they determine 25 the over all program needs, etc., is not as systematic and clearcut as vie Y.,ould like to see it. 2 DR. SCIIERLIS: I guess my problem is instead of 3seeing just one or two projects going beyond the three year 4period -you see a whole array of them, and I would hope that 5they mLght receive very strict and harsh suggestions as far 6,- as how to direct some of these funds. In fact, I would 7be in favor of literally telling them, you know, we% can't 8support X projects for three years, and go on and do something 9 else. 10 The other question I have is for a while written 11 communications were going.back to the coordinaItors indicatin- 12 the exact specific areas of concern. I understand that has 13 bee.n modified, is that strue? 14 DR. MAYER: Can staff help us on'that? 15 DR. SCHERLIS: I was caught in one of those 16 programs of ultra detail communications which went back, and I 17 was curious what the present policy is. 18 VOICE: Are you talking about technical aspects of 19 individual projects? 20 DR. SCIEERLIS: A very frank discussion of what the 21 site visitors have stated in detail. How much of that is now 22 gdin- back to the coordinator? 23 MR. Cllkl@,BLISS: Principally that goes back now in 24 the form of the post Council advice letter. There have been tal Reportefs, Inc. 25 though, some ra 'ions with before, ther frank discuss Greater Delav,,are Valley. Dr. Margulies has been there along with 2 other members of the staffo which included Pete Peterson, I 3 was theret and others of us, and there have been some rather 4 frank discussions with them. 5 DR. SCHERLIS: In writing or-- 6- LM. CHAIIBLISS: I believe they were followed by 7 the visit was followed by a letter. 8 DR. SCHERLIS: I think this is a vital concern here. @9 DR. PE-RRY: I Eu-n greatly concerned and I am happy 10 you mentioned the lack of allied health-representation. If 11 you look at the amount of the projects they have, they do 12 relate to systems, they relate to these areas, That region 13 is not utilizin- resources they have. They have really .14 very strong allied health programs in the University of 15 Pennsylvania$ one at HahDeman. Here are resources that need scir,@ 16 kind of a voice and some kind of relationship to a program 17 that is spending that much money, but they are not involving 18 them. I know in one case Dr. Frank Houston has gone 19 in to R!.IP asking to be involved, and the -said "thank you." y 20 MISS A.NDERSON: In the recommendation, too$ where it 21 says "-lack of appropriate representation of allied health, .22 minorities, and true consumers on the board of directors and 23 the Regional Advisory Groupill they should also say "and staff." 24 DR. MAYER: Right, and staff. I am tr'ing to lc,3 eal Repottets, Inc. y 25 you know,,if'l were liartit) Woliiiian, who has four oil five 245 I vacancies already that are there, with a couple more that 2 are goin- to appear evidently, and I am told that the dollars 3 I have--,.-.-,.@.)r year are essentially the same as the dollars 4 I have for this year, and I have got six months to turn the 5 program around and then I am out of any approved funding 6 anywhere, and I had a little bit of difficulty because I am 7 new trying to recruit those people, and now I have got a 8 new message which is there- and the only thing that I have 9 got working for me is the fact that Rik ,,IP nationally got a 10 30 million dollar increase and at least-there is a general 11 feeling that maybe it isn't going to die after all, it is out h, 12 in the hustings, but that's all I have got going for me. My 13 program sure looks like it is goin- to die, end thbse bright 14, people I am trying to recruit said what, the Greater DeJqware 15 Valley RIIP now I don't knoNy what-kind of chances he has 16 got in six months, which is what he really has, to 17 initiate another grant application to come in here that is 18 different than this and to create a program in six months 19 that is different from--this. 20 I guess I am caught up on the one 'year, two year approach issue in terms of the chances to do this job. 22 DR..HESS: I must say I have great personal regret 23 in not being able to recommend more funding because I think 24 this region is underfunded in relationship to what should be ,ce - Federal Reporters, Inc. 25 done there. And so I am most reluctant to make th..@ I essentially a level of fundillfr recommendation, and I really 2 believe they probably should have twice that much, and the' 3 needs are there if the system were there to appropriately 4 utilize it. 5 But if the question -you are raising is should we 6 make this a two -year recommendation irstead of one in order 7 to give the region, particularly the coordinator, a'iittle 8 more to bank on in terms of recruitment, I am certainly in 9 favor of that. I think we need to do anything we can in 10 order to strengthen them and give them.tlie assist they need 11 in order to build an effective program %,hich will quali y 12 them for the kind of funding that I really believe they 13 should have. 14 DR. MAYER: To what degree do -you think those 15 medical schools understood that whether that R14P is going to 16 survive or not is dependent upon having a strong central 17 core staff, and to what degree are they breaking their necks 18 to try to see that that happens, or are they just glad to 19 keep it nice and weak? 20 DR. ITESS: Well, I would be most reluctant to 21 attribute -- Bill can speak from his own point of vieWT- any 22 lar, who Machiavellian motivation to Dr. Kellow in particu 23 is the one we spoke to. Thq time we spent with him I just 24 liatever; didn't get any feelings of this type abobt him w kce et.31 Repotters, Inc. 25 and whether that's valid or not, I have no way of knowing. It's just gut reaction. But he seemed to understand YYlien we 2 talked with him about the need.to shift the emphais away 3 from such heavy medical school domination. In the feedback 4 we went into this in some detail. We told him re recognized 5 why they were where they were now, that they needed to pull typ., 6,' medical schools together, and those were some of the major 7 resources they had.- to get started with, but now that 8 it was on its feet and going that it was important for 9 the medical schools to move more in the background and let 10 other interests play amore dominant role. And he seemed 11 to accept this without any real difficulty, but again I 12 can't say how much the message got across. But 1, at least, 13 do not have any reason to believe that this has been. 14 overtly intentional on the part of the medical schools, 15 One of the problems that they pointed out is that cif- 16 the difficulty of attracting qualified professionals to 17 essentially what many people see as a SOP operation with 18 regard to RMP. The medical school positions are for all 19 intents and purposes filled, and I think it's more a function 20 of the way people see R.@IP there versus a university base 21 than it is any conscious effort on the part of the medical 22 schools to keep core staff weak. I just don't think that's 23 there. 24 MISS Ai@'DERSON: Are you suggesting a time schedule erat Repoiteis, Inc. 25 or anything for these changes? 248 DR. HESS: No, we just said as quickly as they could do it. We didn't give them an-37 specific time schedule, but we 2 3 told them we felt it was important and urment that they address 4 these problems promptly. hings have been brou-ht up 5 MISS ANDERSON: These t t> 6 before over and over again. 7 M. THURMAN: I think Mr. Chambliss has a very 8 important point. They have been talked to by a lot of people. 9 To go back, Bill, to what you said, I would agree 10 one hundred percent with Joe. I don't believe this s 11 Machiavellian at all. It is more a realization that we have 12 five RI!Pls, and not one, because they are filling all the 131 medical school components, whereas if they devoted.;that 14 degree of effort to really making the core staff one who had 15 a lot of diout they could do it, because we are in a surplus 16 of people right now, particularly where you have five 17 medical schools generating people who could do this and two 18 very good schools of allied health. If you get two of 19 the faculty of one of those'schools they could fill three of 20 the positions that are open if they would just get together 21 and talk about it. But they are operating five little R@fP,s, 22 is what they are doing, and they are not looking at the core 23 staff. But I don't believe it's by design. It's just by 24 the fact that Temple is not really going to shake the hand deat Reportefs, Inc. 25 of the University of Pennsylvania too hard. They will meet them once a month for dinner, but they are not going to shal@e their hand too hard. And that's where the weakness really 2 3 comes up. And that's why I think again, to go back to what 4 Joe said, I would be opposed to going to more than one year 5 because I think they have got everything they need to make 6 this a going operation. They have got the demand, they have 7 the support of the people around them, and everything else. 8 They need to know that they can do it, and I think they can. 9 DR. MAYER: Leonard. 10 DR. SCIERLIS: From a practical point of view I 11 would certainly agree with what the Chairman stated, that -you 12 can't go and hire anyone really of any stature if he only 1 3 thinks he can work f or one year. This has been one of the 14 difficulties with not just getting staff, but of keeping 15 staff. And I question whether or not this is the way to 16 strengthen a region by telling them they will get no money 17 whatsoever unless they shape up and at the same time give 18 then no way to do it. 19 And what I was wondering would be the following. I 20 think that if 'you look at how they are spending their money, 21 one and a half million is core, and they only have oflotal 22 projects about 400,000 for projects.- And if you look a 23 those projects practically every one of them is outdated 24 in terms of it has been over three 'years,, and they are just .ce edeil Repot ters, Inc. 25 supporting them for much too long a period of time, and this st their operating level Of 1.9 is how they get the reque 2 direct. I don't have a specific number, but I guess I could 3 come up with one. I 'would be more in favor of giving them, sa., 4 two years of support, but knocking that 1.9 down and then in 5 the second year givin- them a sum that would at least enable 6 their core and some projects to function, because if you 7 gave them, for example, 1.9 for that two years away period 8 they are going to have nothing to support unless they keep 9 going on their projects,,,and that's an'easy way to go for it. 10 My feelinm would be something on the order of 11 say they have to shape up and let's Out it down to 1,7 this 12 year and 1.25 the following -year, if you can really come up 13 with a pro-ram we will accept an application year,after,year. m t 14 At least they can hire someone for a two year period of 15 time. 16 I think 1.9 -is high, andI think that they won't be 17 able to really shape up if vie don't promise them some support after that one year period. I don't see how you can go out to 19 a professional person of some stature if you want him in core 20 and say "well, if we really do well we will hire you the 21 second year, but it looks like it will be a One year period.''- 22 DR. MAYER: And two -years doesn't, you know, bother. 23 me. Bob Marston always used. to say that, -you know, two years 24 is forever. God knows what's going to happen in two years, c al Repoftets, Inc. 25 whereas one year is not quite that, and neither is 18 months. 251 But two years, you' know, is a pretty solid time term. -o 2 DR. SCHERLIS: I'm concerned about that 1.9 because 3 1 do have this concern about continuity of ongoing projects, 4 and we are really telling them to continue what they are 5 doing but do it better, whereas if we put some stringency on aid ,,6' say the only reason -you are getting that other year is 7 because ive'feel -you have to get some core staff to carry this 8 on. I am Dot making this as a motion because I want to .9 see what your reaction would be to that, Dr. Hess. 10 DR. liE8S: our thought was they they indeed could 11 begin to tackle the issue of phase out by trying to fund some 12 of the new projects that they would like to by phasing out 13 some of the old Ones. This .vould give us a means.of findin- 14 out when we review another year whether or not they'reall.y 15 had established some goals and priorities that they were 16 making operational, and we felt vte needed to give them a 17 little meneuverin- room in order to do this. 18 Now -your real question is how much, and if we cut 19 them back too much will they be able to fill those core 20 vacancies they went to fill in light of their ongoing obligatii)i 21 to people out in the field that they have to mainta n some 22 kind of credibility in terms of funding. 23 DR. SCIMRLIS: I really feL,,i more strongly about 24 that second year of support. Do you feel it should be zeroed kce-Fedetal Repotters, Inc. 25 in view of the discussion? DR. HESS: No, I would be perfectly willing to shor, 2 support for the second year in.order.to give them something 3 to banlt- on. think that's sound. 4 DR. MAYI,:R: The request for core in the second year, that includes all components of core, central core plus the 5 6 individual schools, is 1.67. 7 DR. HESS: Incidentally, the major increment in core 8 in their proposal as opposed to where they are now is in the med onents. We suggested,to t 9 ical school comp hem that 10 they consider keeping the medical school components at level 11 funding and try and get more out into the field and not 12 put as much in medical schools. 13 MISS KERR: Joe, how long as Dr. Woliman been there? 14 DR. HESS: He has been director since last July. 15 MISS KERR: lllhich is a very short time. And in 16 view of the fact that so many people have been talking to 17 the director, and so forth, perhaps it was hard to evaluate 18 on the sitevisit a man who had been there four months, do 19 you think the potential for a more positive leadership was 20 there? 21 DR. HESS: He was deputy director before, so he is 22 not brand new to the program. I just don't know. 23 MR. CHA-TilBLISS: If the committee would just permit 24 me to act as a volunteer here, may I say that in these ce I Reportefs, Inc. 25 complex metropolitan areas where there are multiple medical I schools there are very definite problems in getting the 2 R,@IP going. lVhether they need additional time I personally, 3 cannot say. Whether it will be additional money I cannot say. 4 I do have this feeling, though, that it centers around the 5 element of leadership of leadership of a person having 6 a certain amount of boldness, who is willing to get things 7 moving, and I think we have seen this very candidly expressed 8 already today in the Illinois situation. 9 So what is the element that these complex metro- 10 politan areas need that we can provide,, and I think this 11 element of leadership is one of the sine qua nons of which 12 it will not move unless it has. 13 Now you make the-point that this coordinator has -14 been there since July, and the point is reinforced by the 15 fact that he was the deputy under the previous coordinator 16 for some time. We need your help here in tr ing to find what 17 are the elements' needed to get this kind of R@IP under way, 18 to help us examine what you think ought to be done and make 19 some recommendations in accordance thereto. 20 DR. SCHERLIS: I have a certain allergy at least 21 to working after 5:00, but the problem of seeing a core budget 22 which has inner cores and outer cores and peripheral cores,-- 23 and this core budget is one which has $750,000 for the inner 24 core and another $750,000, $iiO,000 plus-or minus 20 I guess eal Reportets, Inc. 25 was the number they agreed upon, which Would be centered e-roul-d the other six medical schools. And I think one way to preserNC 2 a weak RIIP is to have a good portion of that budget not 3 under his and the RAG's domain. And as I read this my concert 4 would be that one message that should go back would be that at state, and not 5 the core should really run the RMP in th 6 be subservient to all the other cores which operate, and I 7 would assume fairly independent. And if they want to 8 set up projects in the other medical schools, in one.schooi 9 where Dr. Pastore is, and if his thing is peer review and 10 continuing education and ambulatory care@which he does in exemplary manner, I am sure he can come in with an 12 excellent project which would then be subject to technical 13 review. 14 I don't think you can have a strong RMP where you 15 have a series of cores which operate independently and 16 not subject to the usual type of technical review, and I thin): 17 that's what we are seeing replicated in a great many urban 18 areas where we have a great many medical schoolfoperating. 19 And I would think that one message to get back 20 here -- this is why the system has worked so well in 21 Chicago. Their executive director makes it very clear that -M 22 he runs that program, and if a medical school wants something 23 they work with him. This hasn't caused any schism, but it, 24 has caused an unbelievable amount of support,Iand I would I Repoiters, inc. 25 t back. think this is one message that should -e 255 As I read core, it is a fractionated, moiticentric, 2 multilayered core. I would like a comment of the site 3 visitors on this. Do I misread that? 4 DR. HESS: I think you are essentially correct, and 5 this is the point that I tried to make earlier, that 6 medical school domination at a number of points in the 7 system is having an adverse effect on the region, and it is 8 indeed going to take stronger leadership in terms,.of the RAG. 9 We can't in a very detailed way evaluate the coordinator 10 and the effectiveness of his function. We do have some 11 serious questions about it, but again-we recognize the 12 short period of time which he has been in the full authority 13 position, and therefore we' sort of hedged on that,,particular 14 issue, but fully aware that this may be part of the crux 15 of the whole problem. It is not the whole crux because this 16 whold board of directors, RAG is another part of it, which 17 until that is resolved I don't think you are going to got the 18 kind of coordinator appointed.that we V.,buld like to see. 19 Now maybe if the center of power shifted that current 20 coordinator would be able to function much more effecgively 21 because he Would have a different kind of power base 22 behind him backing him up at a policyni'aking level. 23 So, -you see, there are all these dimensions that 24 are very hard to got a handle on, and they all directly d,,al Repottefs, Inc. 25 interact. DR . LIAYr.R,. Would somebody care to make a motion? 2 DR. IMSS: I will make the motion. We have made' 0 3 it for 1.9 for the first year, and I would like to suggest 4 that -- pull a figure out of the air --i.7 for a second year 5 so that that gives them some firm funding to count on, 6 and then I guess they would have to come in for 7 an annual application, wouldn't they, another year, another 8 site review, and so on. Is that correct? 9 DR. MAYER: No, wouldn't have to be site visi e 10 DR. HESS: All right. . I would attach a recommendation II- of a site visit in one year to that. 1.9 the first year, 12 .1.7 the second, with a site visit after one year. 13 DR. $,IAYER: Is there a second to that motion? 14 MISS ANDERSON: Do you want to reverse those 15 figures? Wasn't that what you suggested earlier, reverse 16 those figures? 17 DR. HE-SS: No. 18 MISS ANDERSON: I'm sorry. 19 DR I.IAYER: Further discussion? With, I assume, 20 a clearcut understanding that not only verbal, but written 21 message needs to get back that incorporates much of what 22 has been said. 23 DR. SCI-LERLIS: I did not see in the site visit 24 repor t specific reference to these multi-pie cores. I kce eal Repoitets, Inc. 25 would hope that that discussion would be incorporated in the 257 he. unit, because I expect the Greater I evaluation of t 2 Delaware Valley area will not move from where it is now 3 unless these counter cores become subject to their 4 coordinator. I don't see how it can move. 5 Dr. Mayer, do-you want to comment on that? Do -you think that should be part of the recommendation that goes 7 out? 8 DR. IIAYER: (Nods.) 9 Further comment, discussion? 10 All those in favor, "aye 11 (Chorus of "ayes.11) 12 Opposed? 13 DR. THUR",IAN: Aye. 14 DR. SCITE@RLIS: I think I should ask the Chairman 15 to speak. up and not move his head because that doesn't go 16 on the tape. You expressed concurrence. 17 DR. @LKYER: What's that? 18 DR. SCIIERLIS: I don't know if the tape heard you. 19 You agreed, didn't you? 20 DR. I.IAYER: Yes, I did. 21 Let us move on to Louisiana and then we will call 22 it a day. 23 DR. WHITE,: Normally I come to this point in time 24 feeling fairly comfortable about how I feel about the region ce deit Repotters, Inc. 25 1 visited,and I have adopted a position and I try to persuade I 258 you to adopt the same position. At this moment I feel 2 that I probably will be a twig which bends with the winds 3 that blow across this table during the discussion, and I 4 say that because I never really got a very definite kind of 5 feeling about anything specific about the Louisiana Regional Medical Program. 7 'This is in part my own fault because I was helped 8 by a superlative team of site visitors, including Mr. parks 9 and our staff from here, and I guess it's because I tried 10 to mix business and pleasure. As my wife a@d I viewed the 11 stark, bleak, white winter of Wisconsin ahead of us we 12 decided that perhaps she should go to Louisiana with me. 13 But I find that it's difficult to have a second honeymoon and 14 be an effective site visitor at the same time. Neither one 15 was accomplished to my satisfaction. 16 (Laughter.) 17 I think that to view the Louisiana program one has 18 to recognize some of the encrusted attitudes that exist 19 in that state. They take great pride in thei r crawfish and 20 oysters, and I think that there are other shells in that 21 area which are difficult to penetrate or to crack open. 22 You may recall that there was some early trouble 23 with the development of the Regional Medical Program of 24 h a past presiden Louisiana, that Dr. Sabatier, even thoug Ce- 'fat Repoftets, Inc. 25 I believe, of the Medical Society, was at one time to be 259 expelled because lie expressed some interest in the Regional 2 Medical Programs. So he has had a tightrope to walk, and 3 he has had some difficult problems, and only now is he beginning 4 to get some consensus on the part of organized medicine and 5 organized health facilities that maybe the Regional-Me(iical 6 program has a place to play in the state of Louisiana. 7 Another problem relates to the two systems of healtl 8 care that exist in that state. There is a system of state 9 hospital around Louisiana, charity hospitals. These have 10 been in existence for some time, they are pretty well 11 established, they are supported by the medical colleges. 12 The medical schools find them essential in their educational 13 pr ograms. But it has created not an iron curtain;nor a 14 bamboo curtain, but sort of a gauze curtain between the 15 private and the nonprivate health care systems in the state 16 of Louisiana. 17 Further I think that the Louisiana medical program 18 has suffered, in my view, from the sufferings of the 19 other Regional @tedical programs. Sometimes the signals 20 they have had from those of. us who have made site visits 21 or from staff or from the Council have not always been those 22 that served them well over periods of time. By the time 23 they began responding to that signal new ones were coming 24 down the pathway. But I think that this is not the fau @c;e-Federal Repotters, Inc. 25 of Washington alone or the Peds alone. I think that the 259 I expelled because he expressed so@me interest in the Regional 2 Medical Programs. So he has h,,qd'a tightrope to walk, and 3 he has had some difficult problems, and only now is he beginn nc 00 4 to get some consensus on the part of organized medicine and 5 organized health facilities that maybe the Regional Medical 6 program has a place to play in the state of Louisiana. 7 Another problem relates to the two systems of healti 8 care that exist in that state. There is a system of state 9 hospital around Louisiana, charity hospitals. These have 10 been in existence for some time, they are pretty well 11 established, they are supported by the medical colleges. 12 The medical schools find them essential in their educational 13 programs. But it has created not an iron curta"1. in nor a 14 bamboo,curtain, but sort of a gauze curtain bet%veen the 15 private and the nonprivate health care systems in the state 16 of Louisiana. 17 Further I think that the Louisiana medical program 18 has sufferbd, in my view, from the sufferings of the 19 other Regional Medical Pro grams. Sometimes the signals 20 they have had from those of us who have made site visits 21 or from staff or from the Council have not always been those 22 that served them well over periods of time. By the time 23 they began responding to that signal new ones were coming 24 down the pathway. But I think that this is @not the fault ,ce-Fedeial Reportefs, Inc. 25 of Washington alone or the Feds alone. I think that the 260 Re-ional Medical Programs in the context of our earlier too lon- waitin- 2 discussion today have been hanging around 3 for someone to put a hoop through their nose or ring through 4 their nose to lead them down the path. Seems to me the d enou-h, nonspecific 5 guidelines and messages are broa 6 enough that the region should be able to define its own 7 programs within those and not wait for specific'types of 8 statements that they can voice back. Louisiana has been 9 guilty of this, end still is guilty of this. 10 But in honesty and in fairness to them I would say 11 that they have gotten into the planning of things to a 12 great extent because this is what they %,ere told to do by 13 previous site visitors. And this is one of the difficulties .14 we see at the moment. 15 They and CHP have blurred images. It is difficult 16 to sort them out. They indeed have become the planning 17 body for the state of Louisiana., They are not an action 18 oriented group. 19 But I dOD'tvant to leave you with the impression 20 that there is no quality in this program, because there is 21 quality. I think if they were now approaching the state 22 of asking for an operational grant this would be just dandy. 23 But they are asking for a triennial grant, and this has to 24 be viewed somewhat more critically. kce-Federat Repoiters, Inc. They have inde-ed established goals and objectives. 25 261 I They both say the sayqo thing in different words. They are 2 going to deliver better care to the medically disadvantp--ed, 3 they are goin- to increase productivity, they are going 4 to contain costs, they are goin- to develop the that are necessary, and 5 additional kinds of health manpower 6 so on. These are the same kinds of words that we have 7 heard over and over again. They are laudable, to be sure; 8 but I don't see really any clear view as to how these are 9 going to be implemented in the state of Louisiana. Nor do 10 I see a clear understanding of the priorities for the actions I 1 to be taken to implement them. 12 'They have indeed a well established data base now 13 for the assessment of the needs. But I don't kno that they 14 have undertaken this assessment. They have the data, but 15 I don't see that they have clearly.used these data to predict a 16 goal and objective for them. 17 Again, howeverI don't want to be negative. These 18 people have accomplished things. They do have, as I said, 19 these data. They have used them in conjunction with.other 20 health agencies in the state well. They have even been 21 requested by the State Medical Society to provide some data, 22 and I think this is a mark of distinction for this Regional 23 Medical Program because they. were never even regarded with 24 anything prior to that. They have planned with area health ice-Fedefal Reporters, Inc. 25 planning councils, Now Orleans and State Health Departments; they provide a data base which are helpful to them as well 2 as to R@IP. 3 They have developed methods for studying 4 immunization problems which has been helpful in upgrading 5 care in certain areas. 6 They have been able to determine needs for certain 7 types of allied health manpower which may be helpful to 8 Dr. Peterson and some of the others in the future for 9 determining the programs to be undertaken by the respective 10 schools. 11 They have on-e mark which I think is helpful. They 12 undertook a study of irradiation therapy capacities in the 13 state, and on the basis of their studies the hospitals 14 recognized that there wasn't a need for each of them to 15 develop a facility there was an adequate base for care at 16 the present time. And I think this was a significant 17 accomplishment. 18 They have broad support from the pathologists 19 in the state because they were helpful to the pathologists 20 in developing a laboratory standards committee and quality 21 controls which were applied to most of the state laboratories. 22 and I think this is a mark of distinction, too. 23 So'I am presenting a picture that is mixed 24 obviously. There are some accomplishments, there are many kcibral R'ePofters, Inc. ,25 weaknesses. But I don't think we should focus just on the 263 weaknesses. 2 Another point in their favor is that they have been 3 able to.phase out-r-even though their evaluation and review 4 mechanisms are rather weak, somehow or other they did manage to 5 identify one particular project at least that was not meeting 6 its objectives and goals and was just wasting money, and they 7 terminated it. 8 The have been able to find certain kinds of support y 9 for some of their other activities. The Heart Association 10 is going to continue supporting the cardiopulmonary. 11 rescussitation program. The State Department of Health will 12 continue to provide funding for the health information- 13 clearinghouse project. The Louisiana Medical Society has 14 indeed subscribed to and supports the dial acce ss program 15 that was created by RMP in that area.. 16 Minority interests are not really represented even 17 in a token manner, and certainly not represented, I be.lieve, 18 in the deliberations that are necessary for the plan of 19 action that is required for the state of Louisiana. They 20 expressed an interest in recruiting additional minority and 21 disadvantaged participation with a view that they were going to 22 do this through the CHP B agencies. They were indeed going 23 to use these agencies as their subregionalization or local 24 area councils. And to me at least this seems a dubious way of kc al Repoitefs, Inc. 25 going about it. I am doubtful that the people involved in 264 I CHP creation are likely to be any more concerned about 2minority interests than has been the RAG of the Regional 3 Medical-Program. 4 We saw little to indicate that black physicians were 5 involved, black citizens involved. We saw little in the way 6 of Indians or the Spanish speaking people. And this is 7 certainly an area which needs strengthening. 8 Dr. Sabatier is a-good man. He has provided good 9 leadership. He has been able to be persuasive, has been able 10 to meld things together. To me he is not a particularly 11 dynamic individual, and he may not be the kind of guy that 12 can rock the boat that someone talked about here earli.er 13 in another program, and perhaps this is a time that;this needs 14 to be'done in Louisiana, I don't know. But I think he is a 15 talented man, and he is skillful, and he has brought together 16 a good core staff. Surprisingly, their background would lead 17 you to think they are not very capable, but they are. Few of 18 them have had any education in health fields or management 19 fields. One was an airline stewardess who somehow or other 20 got into the Regional Medical Programs, and I think is doing a 21 heck of agood job, as well as being very attractive. 22 They have worked well with other health agencies in 23 the community. I.think they have created visibility for the 24 Regional Medical Program. The Regional Medical Program Ace-Fedegal Repoiters, Inc. 25 through the efforts of core staff and Dr. Babatier I think now is regarded a,- a resource to be called on for help in the 2 Louisiana region, and perhaps this is a right time for having 3 been identified as a resource to begin acting. 4 I won't go into further details about how the core 5 functions. There are strengths, there are weaknesses. They 6 mana-e things very well. They have fiscal management which is 7 very good. They have been subject to audit without-fault. 8 I think their evaluation procedures within core are 9 somewhat weak, but this is not peculiar to Louisiana. 10 The review process for the review of new projects 11 is rather sketchy, and this obviously needs strengthening. 12 But this relates to a problem that we will get to a little 13 later, and not too much later because I see thatls,.on the 14 next page, and that's the Regional Advisory Group. 15 AlthoughJhirly representative of key health interests 16 in the state on paper, I think we came away with the feeling 17 they didn't really participate very much. There were allied 18 health people listed, there were hospital administrators 19 listed, there were medical school deans listed, there were 20 medical society representatives listed, and so on. But it 21 was difficult for us to get a grasp of any facts that would 22 lead us to think that they actually participated, particularly 23 in reference to defining the programs for the state, what 24 they should be and what the action plan would be.that would Repottels, Inc. 25 be likely to achieve these objectives and goals. -They met I infrequently, they did not serve on any of the committees. They did not function in reviewing the projects other than 2 3 to look at what was handed them when it finally came to the 4 time of a Regional Advisory Committee meeting. 5 Surprisingly enough, some of them, I guess, had 6 recognized this same weakness in themselves, and they had 7 undertaken a task force analysis of the Regional Advisory 8 Group roles, and they have indeed identified certain 9 weaknesses and certain faults, but when we asked them what was 10 to be done about this we got no really clear conception. 11 it was sort of an apathetic "gee, I guess we really aren't 12 doing what we should do, fellows. lYe know that," but hadn't 13 really thought that maybe they should do soniething.about 14 the fact that they weren't doing what they really should be 15 doing. 16 Well, this I think, in my opinion at least others 17 may have a different view of Regional Medical programs in 18 Louisiana -- this is a major weakness. This is not a program 19 in which people participate. 20 The Regional Advisory Group is sort of a window- 21 dressing affair which may or may not be rubberstamp. I 22 don't know whether that's even the appropriate term. They 23 just don't participate. They must be made to participate. 24 And we have some recommendations to make -in our overview of @,,-ral Repofters, Inc. 25 the program with Dr. Sabatior when we finish. Related to this is another program,and that is 2 the relationship to the grantee organization. The grantee 3 organization is a nonprofit corporation with a nine member 4 board of trustees defined as needing to incorporate an 5 economist, an engineer, and certain other people, so t e 6 flexibility that the Regional Advisory Group has in appointing 7,' members to this is very slight. It must include the past 8 chairman of the Regional Advisory Group, the medical center 9 officials, and a member of the State Medical Society. 10 In reality this group ligs full veto over anything 11 the Regional Advisory Group does. Now they tell us that this 12 has not occurred in the past, that they have not indeed ever 13 vetoed any decision made by the Regional Advisory Group, But 14 I fear in my own mind that the time has come that if the 15 Regional Advisory Group does become.active, does find a 16 spark that gets it going, that there may be some conflict 17 which comes about. There is the.one trustee structure which 18 likes status quo and don't rock the boat, and another one 19 wants to start doing it, there may be areas of conflict 20 that come about; and this relationship should be straightened 21 out prior to that. 22 Many of the health interests in Louisiana are 23 involved in programs. We don't see that any one of them has 24 co-opted the Regional Advisory Group. No problems really I Repofters, Inc. 25 in relating within the health structure at the present time. This has improved, said, from the past. The relationships between R,@,lp and Clip, difficult 2 3 to straighten out, largely because R@iP has been doing what 4 Clip would be expected to do, I think, and this is reflected 5 in the attitude of people in the state. They have a blurred 6 image of what R,@IP should be and what CHP should be. And a 7 Dr. Acory, who was appointed -- and I have forgotten exactly 8 how this came about -- but in any event he was appointed 9 by somebody in authority to try and define what the respective 10 roles of these two organizations is to be, and he confussed 11 to us in o pen forum that he didn't really know. And I kind 12 of got an idea that he wasn't terribly concerned that it be 13 c.leared up. I am not sure that he is the kind of person 14 that should be conducting that study. 15 I mentioned local planning and that we felt that 16 perhaps this was somewhat weak because it was going to be 1 7 dependent upon CHP B agencies. We saw little involvement by 18 actual citizens of the state. What we saw was not terribly 19 heartening. 20 They did have one, project which was called consumer 21 health education programs, and .we had others that had to do 22 with helping people to got into the health care system, both 23 apparently grass roots sort of project. But we weren't 24 terribly stimulated by the individual who presented that to .ce I Repoitefs, Inc. 25 us, weren't sure that the concepts were entirely correct, l@ wondered whether this, too, was sort of a window dressing 2 to prove that minority interests or disadvantaged people 3 were actually getting represented. 4 As I mentioned, they have an excellent data base. 5 I won't repeat that further. 6 Their management is adequate. Their evaluation is 7 weak. 8 The action plan there really is not much of an 9 action plan. They have said that they are going to improve 10 certain things. They are going to improve health care for the 11 disadvantaged, but look at what they are going to do. They 12 are going to create a half a million dollar coronary care 13 center in the New Orleans Charity Hospital. They are going 14 to create a half a million dollar pulmonary pediatric center 15 in the New Orleans Charity Hospital, and they are@going 16 to create -- I have forgotten -- a renal pro-ram within 17 the Charity Hospital system. Now they say this will help health 18 care because all of these guys are trained by the medical 19 schools and the Charity Hospital, therefore they are going 20 to go out to,the charity hospitals in the rest of the 21 state and automatically this will bring better care to the 22 people of the state. Well, we know that this may or may not 23 be true. These doctors trained in Louisiana don't necessary 24 stay in Louisiana. If they do stay in Louisiana they will t'r-c'-Fedetal Repo[teis, Inc. 25 go in d once they go into -private practice in large part, an I private practice the relationship to the charity hospital So it is highly tenuous sort of 2 system becomes quite weak. 3 reasoning that they have used. 4 They'have created priorities which I will read 5 to you. The cardiac care unit is the number one priority. 6 This incorporated the spending of several hundred thousand 7 dollars for equipment. Something having to do with shared services, and this is a pro-ram which rural hospitals would r.> 9 define what they can do in-concert better than they can do 10 separately. A tumor registry is number.three. And I have 11 always had a bias, I never did quite clearly understand 12 how tumor registries related to bringing better care to the 13 rural and disadvantaged people. 14 -A regional kidney program is four. Health date 15 information center is five. Cardiopulmonary roscussitation 16 unit is six. Stroke discharge planning, seven; pediatric 17 pulmonary planning, eight; organ, number nine, and that has 18 been phased out; and a health consumer education and citizens' 19 advice bureau, the last two in their order. 20 They have been instrumental in developing some kinds 21 of continuing education programs around the state for the .22 nurses, the dial access program for physicians, and so on. 23 I think I shall not go into further detail about 24 this. I think I.have covered the points that I think are of al Repotteis, Inc 25' concern to me, and I would rather turn to Dr. Parks at this I time before we get into telling you Nliliat our specific thoughts 2 might be as to funding and other recommendations. 3 IIR. PARI@ -Weil, due t6 the lateness of the hour 4 and the completeness of that report, I can agree with most 5 of it. There are a couple of things that I think I should 6 probably highlight. 7 There was a lot that I didn't see in that room. 8 I did walk the streets, I took the lunch hour and walked the 9 streets to see something of the population, to see if I 10 found any kind of representatiion in that population within 11 the confines of the room in which we were conferring. I did 12 not fiDd it there, and I think that ha s been covered somewhat' 13 adequately. 14 I happened quite accidentally to ask the' black 15 receptionist that they had about opportunities for 16 advancement, and she mentioned to me that she had just come 17 on board the week before. So I assume from that that the 18 word went out that there probably would be a black on the .19 rev@w thing.and they ran out and got a lady. 20 This troubled me a little bit, but I leave that 21 just as an example of the kind of thing that occurs here. 22 There was another black fellow, his name was 23 Bonner. lie was a parish agent for the Department of 24 AgricQlture. lie was very gi.ib, but largely impertinent al Reporters, Inc. 25 in terms of the information that he gave us; impertinent not se.nso, but impertinent in the insulting in terms of what he was addressing. 3 We talked with @Ir. Roberts, who is the Assistant 4 Director for Administration. Ile is avery able man. He 5 mentioned some problems which were fiscal which were occasioned by late funding, and this was being unable to 6 7 start programs and then getting money in the middle of their fiscal -year. But I think there was some suggestions 8 9 that would deal with that. I did ask him about the question of whether the 10 various programs and activities that they funded at the variou3 11 medical schools and activities throughout the state; with 12 13 respect to regionalization I think they probably had 14 somewhere between f ive and'seven outreach projects that were 15 spread in different points in the state. But he did indicate 16 to me beyond receiving a certificate of compliance they 17 did no monitoring to make sure whether the pr ograi-as were 18 in fact reaching the people that they were designed to, 19, whether there were fair hiring practices that were in fact 20 operational, and various other things like this, which I 21 thought was a weakness, perhaps not by intent, but by virtue 22 of lack of direction in that area. 23 The RAG chairman I thought was a disaster. He was 24 the director of the state health system, something like that. at Reportefs, Inc. 25 He was a state official. He was introduced as a-- vate DR. WIIITE: He was a pri practitioner. 2 VOICE: He sits on several boards that have 3 jurisdiction over the state system I think he sits on the 4 state administration of hospitals. 5 MR. PARKS: This is somehow very closely tied into 6 that operation; and to the ex officio appointees to both 7 the R14P and the RAG, in the composition of those bylaws, there 8 is an interlocking kind of directorate really which makes 9 up the executive committee of both. 10 There were apparently problems of turf and rivalry 11 between the medical schools, and, of course, the peculiar 12 problems, the duality of the medical systems that they 13 have there. 14 Now these were presented to me really as ,a 15 reconcilable concomitance of the Louisiana situation, and 16 that Dr. Sabatier, whom I think is a very skillful 17 coordinator, and certai nly I would assume a skillful politician 18 seems to have made some passable accomodation with these 19 competing forces to obtain some measure of recognition and 20 some latitude for movement and development in this particular 21 program. 22 I did detect, though, in the statement of these 23 problems that Ithey were almost incapable of resolution, and 24 that they would be boulders behind which they would hide for Aleral Repoitets, Inc. 25 ooking for in not making certain kinds of changes that we were I I teriTis of action oriented or delivery oriented kinds of activit% 2 The thing came through very directly to me that 3 Louisiana has some very, very peculiar problems, and I did not 4 detect that they had been not only recognized, but met and no@ 5 that they were in a position hopefully to move around them 6 to achieve some other things. 7 I detected two others things. One, that the design, 8 the planning design was sort of an operational device to 9 get around some of the hostility, in addition to having been 10 perhaps an invited error by prior site visitors. The other 11 thing was as a result of that, the heavy emphasis of planning, 12 it did present some imbalance in terms of staffing, and 13 this was with respect to core. 14 There was a coordinator not a coordinator -- 15 what's the name of-- 16 VOICE: Project development officer. 17 MR. PARKS: Project development officer, who worked 18 apparently by himself. And this was really the key man to 19 their outreach and their developmental activity. 20 I would say that ther e are a number of positives, and 21 think the fact perhaps that they have survived and done as 22 well as they have is somewhat remarkable, if what I have been 23 told is true. 24 But I would think,.though, that they should be put @c al Reporters, Inc. 25 on a basis where some of the recommendations will address 275 themselves to this. They can be watched and encouraged to 2 make certain kinds of programmatic and organizational changes 3 that would bring them more into line with the program 4 statements and mission statements that have come from here. 5 DR. MAYER: Care for a recommendation? 6 DR. WHITE: Well, before I do that I would like to 7 voice my feelings about the renal program in the state of 8 Louisiana, in spite of separate or semi-separate or not 1 9 separate funding, or whatever it might be. 10 In spite of the fact that the.technoiogy is 11 apparently available for saving lives, in spite of the fact 12 that some actions have been undertaken to correct what are 13 viewed-as shortcomings in this program, namely that it is going 14 to be phased in gradually rather than ail of,a sudden, and 15 that it relates appropriately to a center for transplantation, 16 and so on, and that people now onanother kidney project 17 won't get paid twice by being on this project, too, and those 1 8sort of things, as I view the project it really does not 19 serve the purpose of the Regional Medical programs. It is 20 going to be a system in the charity hospital system. There 21 is nothing that I see in it which makes it a total system for 22 the state. 23 The fact that we have some documents which indicate 24@ there is some disagreement as to whether or not there sliou d @@r-L'-Fedeial Repoftels, Inc. + 276 I there should be one renal program for the charity and one 2 renal program for the other peopl6. 3 1 think, therefore, that regardless of the funding 4 mechanisms or the categorical nature or what have you, that 5 if this renal program is to survive in the state of Louisiana 6 that it should not be funded at this time, that it should go 7 back through a review process and be looked at by the 8 Regional Advisory Group, and this is a chance that they can 9 either hang themselves or prove themselves as responsible 10 citizens of the state. 11 With that as a preamble, I think the site visitors 12 at the late hour that we met on the SOCODD day came up with 13 a round figure of a million dollars. They had askbd for 14 a million eight, and they are currently functioning at 15 about seven fifty. We felt that this was enough to help them 16 strengthen their core. It might also be enough to entice 17 them to do something.other than to strengthen their core. 18 And this might be a measure again of their maturity and 19 ability to handle their own funds and establish -Eheir own 20 priorities, and give us further evidence to base our judgments .21 on in the future as to whether there should not necessarily 22 be a triennial R@IP, but one at all in the state of 23 Louisiana. 24 There is a problem in reference to t.he coronary %ce-Federai Reporters, Inc. 25 care units. This was previously approved by this body prior 277 I to the time that there was any interdiction on the use of 2 funds for equipment. They feel that it is perfectly 3 legitimate under those circumstances for them to proceed with 4 this. I don't know that we should give them direction along 5 these lines. This again would be a measure of whether or not they are capable of managing their funds and programs 7 appropriately. 8 So I think our recommendation is for a million dollars 9 with a message, and that their fate is in the balance and 10 will be determined by how they manage this million dollars. 11 DR. MA'i"ER: Do 'you want to comment about the 12 discussion vie have now had times two about the two year 13 funding? 14 DR. WIIITE: I have no object ons to that. That will 15 be all right -- for myself. I don't know how Mr. Parks 16 feels about that. 17 R: The question being do we make acommitment DR. MAYE 18 for a second year at some level so at least they are assured 19 of that kind of two -year continuity while they spend the 20 year to try to get ready to put something back into the 21 system. 22 MR. PARKS: lVelip I have not really consulted with 23 anyone about a second year type of funding. But I would 24 say this, that from one of the discussions here-I think it Fedeial Repor tets, inc. 25 is very true that faced with the coordination or direction of 278 I the program, especially charged, say, with a direct 2 immediate responsibility of making certain kinds of prograr@imat@-c 3 changes, having the people aboard who will be necessary to mak@ 4 creditable changes is a very important part of it. And I 5 would assume that the life expectancy of a program is a very 6 great factor involved in determining whether a person will or vi 7 not remain in, the program. And I think with some of the 8 recommendations that we have here it might be appropriate for 9 us to consider some figure. 10 I ami not prepared at this time to make an estima e 11 of what a figure should be for a second year. I would think, 12 though, that some consideration ought to be given to'it 13 so that it would not appear that we are asking them to improve 14 for one year and beyond that, there is no light at the end 15 of the tunnel. 16 DR. MAYER: Could you and Dr. White come up with @17 a figure by tomorrow for us? 18 DR. I'IHITE: Well, I think at the time of the 19 deliberation on the figures at the time of the site visit 20 we were fairly much in agreeme nt that a million dollars was 21 an appropriate figure, and I would see no reason why this 22 wouldn't also be appropriate for the second -year. 23 DR MAYER: Leonard. 24 d have to comment. DR. SCHERLIS: You know I woul @ce-Fedetal Reportets, Inc. 25 This is the only time I have had to say heart all day, and 279 itt,,,@ Price to mention that word in a categorical area. I 11'@,ve alot of concern about half a million dollars 'IO gr-"""i', into the coronary care training unit. I have concern ab cltll@ the way it is described as including remodeling of pyi,es,@,I),t heart station, expanding the cardiac catherization L @bo@t@gtory, remodeling the outpatient cardiac clinic, 7 c@onstittation, computer techniques, continuing coronary care, @d t4iso it mentions physicians and nurses. ngs strike me. One either the mail is One or two thi glow between here and New Orleans,. or else the V"lisiltJ.Iit-y of the smoke signals isn't very good. But I 12 w@Oul@i think that had this been submitted even thre e or four Y,' ago that I would have had a great deal of reaction 1 4 which was negative. I think that any place in t 15 @,Dunir could come up with this project regardless of how good y they have a real need for a 16 program is. If 17 6orciiary C-a-rb unit that something in the neighorhood of 18 30 thousand dollars would be appropriate just to 19 Ket I'lie bare bedrock monitoring equipment in place, and 20 I;hat oinethidg going. %youle be generous. I am sure they have s 21 I think at this time to ask for a catherized adult @2 Car(ii.ac clinic and to have particular EKG interpretation - 00ml"kiter assistance is some-khiDg that I would look at with a groat deal of question. I would hope that there would be an iliLiication that this will not be supported, but if they I come in with something for a continuing education program 2 on heart disease I think this is more satisfactory, because 3 this to me is out of line with not only the now directions, 4 but the old priorities as far as the Regional Medical 5 Program goes. If you can deduct that, which is a half millior,. 6 dollars, you still leave them with a good boost for what 7 they have. 8 I don't think we should say to them we are going 9 to look at how mature you are by whether or not you build 10 that. I would first build it, and then after I build it 11 say I have suddenly become mature and I am not going to do 12 it again. I would not want them to be supported for that. 13 And it appalls me in an area with the need of this particular 14 state, Louisiana, that a million dollars of their request 15 goes to support basically to support pediatric respiratory 16 care unit and the rest to refurbish a heart station in a 17 hospital which should be done through other sources, however 18 tight they are in that state for support for health. 19 To end up with, if you are really raising that 20 $250,000 over what they requested this yearin spite of the 21 failure to recognize priorities and goals, and so on, I 22 think I share the confusion one might have with the dual 23 mission that made you go down there, Dr. White. But I do 24 have some concern -- perhaps you could react to.it -- how do Reportefs, Inc. 25 you feel about that half a million dollars? Don't you think 281 .1 we should put a strict no on it, and say well, maybe a few 2 dollars for training, and the increment of $250,000 over 3 the present level of funding might be something they can 4 work with if we are very strict about what the guidelines 5 are, 6 DR. WHITE: Well, their presentlevel is seven fifty, 7 and we recommended a million. And I think the message we 8 were trying to get to them, hopefully will get to them, the 9 bulk of that should be used to strengthen their action 10 planning functions, and the core staff.and personnel required 11 for that. If there is something left over it is obviously 12 going to be insufficient for spending to the extent that 13 they are planning for either the pulmonary or the., coronary 14 care unit. They could then perhaps use 25 or 30 thousand 15 dollars to implement an educational program, but they would 16 not have the resources required to begin to do what they 17 are planning to do for the coronary care. 1 8 DR. SCHERLIS: I would hope we would go on record as 19 saying these funds should not be used for that particular 20 project. Now if they had come in with a system of coronary 21 care for the stat e I would have urged strongly that it be 22 supported because I think Dr. Burke and his group have men 23 that could do this. What we are talking about essentially 24 is going into a university hospital resource and totally @'al Repo(ters, Inc. 25 remodeling all the cardiovascular facilities on a single shot basis, and I don't think this is a proper way of using these 21 funds. If they had asked a half million or million dollars state and set up a total coronary care 4 progr@ii stratified system I would be all for it and 5 I would urge this group go in that direction. That I think 6 is a proper expenditure of R@IP.fUDds, but not to refurbish 7 this sort of a unit. 8 DR. MAYER: Between the coronary care unit and 9 the renal program and the pediatric pulmonary care .center 10 there is j.ust a Ilittle bit over a million dollars that is 11 involved in that, and I heard Dr. White, I thought, a couple 12 of tinL-s comment about his concerns about those two programs 1 3 as-,well as the coronary care program. 14 Are we implying that we feel that those three 15 issues are inappropriate directions to be taken? 16 DR. WHITE: I think they are inappropriate, 17 and particularly inappropriate until such time as the 18 Regional Advisory Group can come back and justify their 19 appropriateness, which they haven't done at this time. 20 DR. MAYER: Would we like to put a limit then that 21 no expenditures in those three areas would exceed, let's say, 22 $25,000 each? 23 DR. Wli I T.E It's acceptable to me. I indicated in 24 advance that I would bend with the wind, and I so bend. .1 Repoiters, Inc. 25 VOICE: I would like clarification. The'throo areas were pediatric pulmonary, coronary care, and wlitt,l 2 was the third? DR. MAYER: The renal program. Yes Dr. Hinman. 5 DR. HINMAN: I would like clarification on tl,,,, 6 renal, what you were saying, Dr. White. Is that the,it/..!i Of if 7 they could meld the two systems that ave deve oped 8 independently into one that you feel it would be approve,/ l.ate 9 to consider the request before their next anniversary, 10 would they have to put it off a year? -The reason I br,,,,@ thi( up is part of the charity system has been supported by 12 some contracts from the kidney disease control program 13 which expire in the next several months, and this woul@ ',a a 14 year before we could even entertain further applicbtio,@-.-, 15 from them, it-would put them somewhere between nine an,: 16 twelve MODths without any income to support their kidnc/ 17 activities. 18 DR. WHITE: Can they get a new contract? 19 DR. HIMIAN: Well, that's another option tha,- 20 Could go. We would prefer the RMPS position would 't,@ 21 to try to work it into the grant mechanism rather than 22 contract mechanism. That's why I brought the question 23 If the answer is that you think it should wc',-,-'@., ,or 24 another year for anniversary then we would have to go -Fifeportets, Inc. 25 contract route to try to salvage some pieces of it if ;&84 seems worth salvaging. 2 DR. VFHITE: Well, Dr. Ilinman, the evidence I 3 have is that the Regional Advisory Group was advised by 4 Dr. Sabatier that there were problems in this project and 5 they chose not to regard the comments that he made,.which 6 I think is a reflection of their activity and interest, I 7 think it's critical that this be 're-awakened. 8 Secondly, we have letters indicating that there is 9 disagreement between scientists as to the appropriate way 10 Of-CODducting this program. Therefore-I think that it 11 requires a strong local review before it can be implemented. 12 DR. HINIIAN: Fine. 13 DR. MAYER: All right, do vye have a clepr 14 understanding of the motion? 15 What we are saying is recommending support of a 16 million dollars for two years consecutively, one million 17 each., with the clear indication that those dollars should 18 not be programmed into such unit development as represented 19 by those three units,-and that the maximum amount of that 20 million dollars that might.go into each of them might be 21 $25,000 each. 22 MR. TOONIEY: I will second it, 23 DR. MAYER: Ali right, any further discussion? 24 All those in favor say "aye." kce-Federal Repotters, Inc. 25 (Chorus of "ayes.") 285 opposed? 2 (No response.) 3 Let us plan then on 8:30 in the morning. We will 4 be in executive session at 8:30 in the morning I would 5 assume probably for about an hour for staff -- this is an approximation. 7 We will in the morning then start in with Western 8 New York. We may have to slip to Metropolitan D. C. before 9 Florida because with Dr. Lowis's absence Dr. Carpenter will 10 be in tomorrow, but he won't be in until about 10:30 or so 11 on the Florida activity. Otherwise our intent would be to go 12 through them sequentially with that one exception. 13 (Whereupon, at 6:00 p.m., the meeting recessed, to 14 reconvene at 8:30 a.m. the following day.) 15 16 17 18 19 20 21 22 23 24 kce-Fedefal Reportets, Inc. 25