I ! I l@ r Al E @HEALI H DIICATION A @@WEL @6EPARrf EN ONAL MEDICAL@, PROGRABIS SERVICE REGT I C01414ITTEE Rockvillb, Maryland Ilednesday,. 12 January 1972 ACE - FEDERA L REPORTERS, INC. Official Reporters 415 Second Street, N.E. Telephone: Wasilington, D. C. 20002 (Code 202) 547-6222 NATION-VIIDE COVERAGE LLEI DEPARTMENT OF HEALTH,, EDUCATION AND WELFARE 2 - - - 4737 3 REGIONAL MEDICAL PROGRAMS SERVICE 4 REVIEW COMMITTEE 5 6 7 8 9 10 11 12 13 Conference Room E, Parklawn Building, 14 RockViii6, Maryland Wednesday, January 12, 1972 15 The meeting was convened at 8:40 olclodk a. m., 16 Dr. William Mayer presiding. 17 18 19 20 21 22 23 24 'e-@Fedefal Reporters, Inc. 25 C 0 N T E N T S page 2 Report of the Director 3 3 4 Information Report on kidney Disease Prograia 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 Federal Reporters, Inc. 25 3 P R 0 C E E D I N G 8 ----------- 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, out hope is that the agenda by the 10 changes in the review process will have provided us a little 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 thoughts 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 ice carrying DR. MARGULIES: I will depend upon my vo 23 far enough, and then if the amplifier comes on I will de- 24 amplify myself, e - Federal Repo@fs, Inc. 25 As you can gee from the agenda, there are a few 4 1 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 we 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 two 10 other people, which means that there will be in many cases 11 a member of the Regional Advisory Group present as well. 12 And the conference was set up around the hope that we could 13 develop during the process of our deliberations a kind o 14 professional discussion rather than one which is dealing, 15 as they go often have, with fiscal issues or with procedural 16 issues or with general questions which have to do wit 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 M6ntal Health Administration, and we will be 23 discussing some of the same things at that meeting that we 24 are going to talk about here, including such things as the E!-Fedetal Reporters, Inc. 25 fiscal outlook for 172 and some of the major program I 5 I interests which have been evolving in R?4P and in the Health 2 Services and Mental 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'totalappropriation which was passed by Congress 9 has been released for RMP, That means a total of about 145 10' million dollars. Of that total about 135 million is available 11 for what ar e not considered direct operational costs, and there 12 have been placed on that total 135 million dollars certain 13 specific and designated uses for funds which I would 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 Federal Reporters, Inc. ,e- 25 the current fiscal year an estimate, which is difficult, I I extremely difficult this fiscal 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 'hing in excess of 100 million dollars for 5 talking about somet 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 RMP has changed considerably, 10 and it means the fact that we are into mid January before we 11 get this confirmation of news raises some serious questions 12 which we will have to talk about during the next few minutes. 13 Now let me go back over some of those earmatkings 14 to get an idea of what the issues are involved in spending the 15 funds because they are being managed in a slightly different manie3 16 from what we had expected in the past. 17 As you remember, the area health education center 18 concept has been a subject of uncertainty for some time 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 23 identified out of the Bureauls budget which are for AHEC. 24 There were also funds identified out of our budget for the same 'e- Federal Reporters, Inc. 25 purpose. There is now being developed and there should be I I completed within the next 48 to 72 hours a process of managing 2 the area health education center out of both resource s by a joint 3 review process. This will 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 6 joint funding or better designed for funding under RMPS 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 contract and how much by 10 grants,, and that question is still under discussion. 11 There will also be developed joint agreement on a 12 set of guidelines describing specifically what is anticipated 13 in an area health education center, and those guidelines are als') 14 somewhere near the point of completion at the present time. 15 There have been significant differences between the 16 position of RMPS and of the Bureau, in which the Veterans 17 Administration has been much closer to the position of RMPS. 18 Over time those differences have gradually disappeared, so we 19 appear to be talking in general about the same thing. 20 When that process has been completed and when 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 get back to in just a 24 moment. -e.-Fedeial Repoitets, Inc. 25 The emergency medical system is also a very recent ]kin I of decision which has grown out of considerations in HEW and 2 the Office of Management and Budget. There is an agreement A 3 under section 910 RMPS can very easily get into the 4 emergency medical service activities. As you know, we have had 5 elements of EMS in various programs around the country for 6 some time. In order to manage that in an effective fashion 7 there was created in HSMHA,again in the Development Division 8 which Mr. Reeso manages, a committee to insure that EMS 9 activities would appropriately involve other programs in 10 HSMHA which are deeply concerned with emergency services. I I There has been for some time an activity in HSMHA which 12 is confined to emergency services. There is the National 13 Institute of Mental Health which, of course, has some major 14 suicide prevention programs and related kind of crisis 15 intervention activities. Maternal and Chil d Health Services 16 is concerned, among other things, because of poison control. 17 And this combination and some other activities in HSMRA are 18 being combined in the form of a general steering committee in 19 which RMPS is active along with CHP. 20 The project responsibility for emergency medical 21 services in this arrangement will be in the Division of 22 Professional and Technical Development in RMPS, 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 'e -Federal Repofte(s, Inc. 25 medical systems will be by contract and how much by grant. 9 1 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 RMPS staff has been involved 6 as the HEW part of it. And it has had a considerable amount 7 of publicity and I believe a considerable amount of effectiven ess. 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. 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 18 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 e -Federal Reporters, Inc. 25 likely in the next fiscal year to help develop stronger 10 I 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 forms 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 lhe 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 RMPS and which is part of the development group. 16 It will be their responsibility to develop the HMO'S, to 17 identify those groups which are eligible for funding for 18 feasibility studies, for planning, and for development. 19 And RMP funds can be utilized for those kinds of purposes. 20 There will be a combination in this activity of grantc 21 and contracts for their development, using some of the contract 22 money for demonstration purposes in HMOIS. There will also 23 be contract funds available, we believe, for furthering the 24 development of methods for monitoring the quality of medical -Federal Reporters, Inc. 25 care which will be used as a part of the monitoring strength I I of RM and of the RMP's as the programs begin to move from 2 a development into an operational phase. That is the 3 Health Maintenance organizations. 4 We anticipate that the RMP'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 10 look at such things as emergency medical services will be 11 in a position to develop special demonstration activities 12 as a part of HMO's to strengthen EhO. 13 The cancer facility which is being 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 HSMHA, 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 gra@ 22 difficulty. 23 Now this leaves us at the point where we can consider 24 a spending plan for the Regional Medical Programs and can con- @ce-Fedefat Repoftefs, Inc. 25 Sider such specific items as the funds which will go into 12 I kidney activiities. We have proposed, and I believe that 2 we will gain acceptance of the idea, that the funding of 3 Regional Medical 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 program development. As 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 increase in funding or of 12 restoration of funding where that has been in issue. 13 There are still some programs which are burdened 14 by the fact that their funds were cut during the last fiscal 1 5 year as a consequence of very limited funding. Wherever 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 eightt 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 RMP support. 24 Now this brings me to one final initial comment or Federal Reporters, Inc. 25 discussion, and that has to do with the potential need to set 13 1 up an additional process or a different time related process 2 for reviewing during this fiscal year. As we are now 3 scheduled there would be a meeting of this review committee in 4 April and a meeting of the Council in May. if we are to offer 5 the opportunity to RMP's to request supplementary funds, if we 6are to consider new proposals for some of the new areas which 71 have just brought to your attention, it may be necessary 8for us to either consider another meeting or to set back the 9meeting 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 programs a longer opportunity to develop activities which 12 they may 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 b have 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 make wise use of it a 21 change from a four times a year to a three times a year review 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 view of the staff of Rh"., Federal Reporters, Inc. 25 particularly the operational Division, if it can be worked I 14 I out in a feasible fashion -- and we haven't gone through all 2 of the dynamics 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 RMPS, 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 review, reporting back the results of review, and then beginning 13 with the next cycle. This means that the opportunities for 14 technical advice, for working with the regions in other 15 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 Medical 18 Prog-r-em. it is a very great problem. 19 On the other hand, if we move from a four times a 20 year,, a quadannual to a triannual program, it would mean that 21 we would have to very carefully adjust the worklo ad on those 22 every four month schedules so that this committee for example, 23 is not suddenly deluged with a large number of total triannual 24 reviews at one time, and can have some reasonable balance in 'Federal Reporters, Inc. 25 the amount of time and attention which it needs toglve to the 15 I kinds of program reviews coming before it. And that takes 2 considerable analysis and planning and a great amount 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 staf f 0 f or the RMP'S. and f or you, in waiting one. month bef ore 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 stage in doing it. It would provide us some kind 12 of funding flexibility because some of the fiscal-years of 13 Regional Medical Programs would have to be changed to 14 accomodate a three times 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 more even utilization of 18 RMM funds in this and in the.next'fiscal year, 19 That last consideration is not an essential one, but 20 in the final management of our grant awards it might be 21 an extremely useful tool. I would not suggest, however, that 22 that be the basis for the decision about whether this change 23 in cycle is worth while., So we really have two 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 16 year for the next review cycle. The other would be to move 2 at that point to a triannual review not triennual, but 3 triannual. 4 These are some of the major considerations that I 5 think are worth considering at this particular point, and I 6 would suspect that you may have some questions to raise about 7 them. 8 DR. MAYER: I only comment, Harold, that as I sat 9 here I was getting warmer and warmer, 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 me go back and pick up what I think must 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 programmatic, 16 efforts of RMPS, you know, striped away from kidney,'@area 17 health education centers, et cetera, et cetera. What is the 1 8 magnitude of that component in your best judgment, and what 19 are your thoughts about commitments towards those dollars on 20 a time span? 21 DR. MARGULIES: We considered a number of 22 possibilities, and what seemed to be the best -- and I have 23 to get affirmation of this -- would be to begin with the base 24 of restoration of funds to all RMP's where they have been .Federal Reporters, Inc. 25 cut entirely on the basis of budget reduction because this 17 was not last year a programmatic 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 rated-r-we will call them A, Bo Ct 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 appears 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 at range, for A programs. in th 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 be strengthen- 14 ing their activities, so that they could be given 15 supplementary 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 programs which are rated C we would not e 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 prudent growth of RegionaJ. Medical 22 Programs. if we should get to the point, Bill, where we 23 couldn't use the funds effectively without giving them to 24 programs which don't rate it we would prefer to return the money ti -Fedetal Reporters, Inc. 25 the Treasuryp which is something that no program likes to 18 I think it is going to do. But we would be consistent. 2 DR. MAYER: We did in 166, 'you know. 3 DR. MARGULIES: Yes. It has 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 Medical Programs 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. They represent 13 essentially the decision of the Secretary, which means the 14 decision of HSHMA in this particular case, based upon t 15 level, the relative ranking of the programs which have been 16 developed through the Review Committee. 17 DR. MAYER: 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. MARGULIES: Approximately 70 million. 23 DR. MAYER: And 'you are speaking --let me see i I 24 am clear then. What you are saying is you are thinking about Federal Reporters, Inc. 25 incremnting commitments towards RKP's of approximately 30 I million dollars then over a time span that presumably 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, according 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, we may find at that particular time 11 and this depends upon our being able to complete the analysis 12 that it would be desirable to expand area health education 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 bur 16 quality monitoring activities. We can identify under tiese 17 circumstances special activities such as a strengthening 18 of our support for the Pacific Basin through the Hawaii RMP, 19 and so on. And there is also the possibility in 20 those circumstances of some strengthening of kidney activities 21 if this appears to be appropriate. 22 We 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 with those nine million dollars -Federal Reporters, Inc. 25 which are still not committed would depend upon whether we 20 I went from a quadrannual to a triannual review cycle, because if 2 we were to do so and We were to take advantage of being in 3 two fiscal 'years at one time 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. MAYER: So what you are saying then is in all 7 probability there will 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-- DR. MARGULIES-. Right. 12 DR. KAYER: With decisions to be made administrative- 13 ly on the basis of, one, those that were administratively 14 reduced, fiscally reduced; secondly, those A programs and 15 possibly B programs on the basis of rankings of this committee, 16 and those decisions to be made by when? 17 DR. MARGULIES: 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 will be affirmed proably this 21 0 22 DR. MAYER: Okay. Questions? 23 DR. WHITE: Is that nine million dollars sort of an 24 RM developmental component? Fedetal Repotters, Inc. 25 DR. MARGULIES: Part of it-- DR. RAYER: Did you all hear the question? 2 DR. MARGULIES: He wanted to know whether that 3 represents an RMPS developmental component. 4 DR. MAYER: That is ten percent. 5 DR. MARGULIES: It really represents more than 6 anything else the potential utilization of it for changing from 7 One type of cycle to the next because that could easily 8 consume six to seven million dollars of it. Since we 9 anticipate -- of course,, we don't know what fiscal 173 will 10 bring us, we will see what the President's message 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 time, 13 but likely at a lower level. 14 DR. MAYER: Leonard. 15 DR. SCHERLIS-. I don't know how the others voted, 16 but when I voted for some of the groups it wasn't with the 17 idea that they were able to utilize any more funds than 18 what we were giving theme Very often a specific RMP would be 19 rated A, at least by my judgment, on the basis of their 20 having all the qualities that go into a good program, but 21 still cutting what they had asked because there was no 22 possibility of them utilizing these funds in a manner which 23 would justify their being granted. 24 In other words, while you stated that some of the Federal Reporters, Inc. 25 reasons were purely fiscal, I question in my own mind how I 22 I y@,u could utilize the large increment that you have stated 2 in a manner which would justify their being utilized 3 merely because these were rated as Als. And also you stated 4 this would be purely an administrative decision, is that 5 correct? 6 DR. MARGULIES: (Nods.) 7 DR. SCHERLIS: I have some questions as far as being 8 able to really spend these funds in a way which would justify 9 that large increment being used. 10 I have several other questions. Can you answer 11 that one? 12 DR. MARGULIES-. Yes, I think the answer to your 13 first question is relatively simple. The level of funding 14 which,you have approved for programs and which was approved 15 by the Council is always way above what they 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 award which is not higher than 65 percent of what 19 Council and you have approved. So you have approved for them 20 levels well above what they are now receiving. There is little 21 reason to doubt that they could utilize the funds which you 22 have agreed they could use. 23 DR. SCBERLIS-. In other words,, as far as the Review 24 Committee recommendations are concerned your feeling is -Federal Reporters, Inc. 25 that when we ask for a full funding only 65 percent on the I 23 I average has been given after the final granting mechanism 2 is that right? 3 DR. ILARGULIES: That's right. There are variations 4 of that, and that is simply because we haven't had the funds 5 to do it. 6 pR. SCHERLIS: Of the total,, which was 70 million, 7 about how much of that is going in now under direct or 8 indirect support of development of HMO'S? You have earmarked 9 16.2. DR. MMGULIES: The HMO is separate from this. 10 11 DR. SCHERLIS: Is it really? I am talking about how 12 in some of the regions a great deal of developmental work s 13 toward HMO'S. What percentage of that, not the earmarked 14 funds. 15 DR. MARGULIES.: I don't know the answer to that. 16 But the amount of money which the RMP's are now currently in- 17 vesting in HUO's is not very great. But we don't have a 18 figure on it at this point. It is not a large sum at this 19 time. 20 DR. SCHERLIS: What sort of review mechanism are 21 you thinking of for AHEC and EMS, and so on? Would that be 22 part of the total review mechanism in a region or would 23 they be separate review mecha nisms? 24 DR. MARGULIES: We haven't settled that issue yet. Fedetal Repoiters, Inc. 25 My own preference on this one is for us to go through the I I review process for area health education centers in a manner 2 similar to what we would do for regular RMP 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 be 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 HSHMA. 11 MR. PARKS: 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 expired 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 programmatic 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 be rather 22 substantial carryover balances that would go to extend 23 pro rams? That is one questio n. 9 24 The next question is this: that shouldn't there be -Federal Reporters, Inc. 25 some review identification of the total problems that you 25 I have within RMP'S, and I am talking now about the program 2 throughout the country, and shouldn't this money be earmarked 3 so that there is some specific onus or burden, i you will, 4 upon these programs to achieve those things that you are 5 trying to get done either nationally or those things which 6 regionally you feel to be desirable? 7 DR. MARGULIES: Let me answer the first question, 8 which is less 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, which is a saving factor in this. 12 The review cycle which was completed in August was for 13 programs which had a fiscal year, their own fiscal year 14 beginning in the fall, in September and in October. At that 15 time we decided to run the risk, or rather I decided to 16 run the risk of anticipating a higher level of funding, and 17 so those programs have already 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 which is , 20 fairly consistent with what I am now proposing. That is the 21 A programs and to some extent the B programs. 22 Now the last review cycle which you completed when 23 you were here last time is for programs for the fiscal year 24 which began January I., so that they have a full fiscal year -Federal Reporters, Inc. 25 coming up, and if we supplement the grant awards which were 26 I initially made before we got the release of funds for them 2 they will have lost no more than one month out of the fiscal year 3 by the time they get to them. 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 with new fiscal years for the Regional 8 Medical Programs, and it isn't as though they were 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. MAYER: Does that answer that particular 14 question, Mr. Parks? 15 MR. PARKS: Well, I assume then administratively 16 you can handle the allocation of these funds. 17 DR. MARGULIES: I think we can. 1 8 DR. MAYER: Without a significant build up in 19 carryover obligation. 1 think that is the question. 20 DR. MARGULIES: I think we can, and, of course, that 21 has always been a problem when you get 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 rightiiow to get this year's -Federal Reporters, Inc. 25 appropriation process finished before July. 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 around 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 activit es 13 for increased emphasis. 14 DR. RAYER: Jerry. 15 DR. BESSON: I have a somewhat complex question. 16 We have a new stated mission for RMPS articulated in the past 17 year, and as a review committee we have been asked to 18 emphasize in our assessment of individual regions the compliance 19 of program regionally with new mission. As I will come to 20 when I discuss the regions which I have been assigned, the 21 staff opinion and the director's opinion aboutthe 22 appropriateness of a particu lar program has to be in light of 23 now mission of RMPS. But yet as I add up these figures I 24 find that we have some 37 million dollars allocated to area -Federal Reporters, Inc 25 health education centers, HMO's., and emergency medical 28 I services, and construction of cancer facility, all of which 2 is consistent with new program. Implicit in this then is that 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 in line with new RMPS directions. Specially when 6 1 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 1 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 we should view that money as having to be 13 spent because if it is not spent it may not be again allocated 14 next year no matter what the program is, whether we 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 as a review committee have to have 18 a little bit more clearly articulated modus 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. MARGULIES: Well, now that is not a complex 23 question. You can do better. There is no question but 24 that there is no implication in the 100 million dollars which Federal Reporters, Inc. 25 is not earmarked for anything other than the new directions I which are part of the mission statement. One year ago today the 2 new obligational authority which had been recommended for RMP 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 Medical Programs 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 new 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 13 we should utilize these funds merely to be utilizing them, 14 1 indicated earlier, if there is not an effective way to 15 use them in a manner consistent with the mission statement 16 and with the total directions in which we would like to see 17 the RMP's go then we certainly shouldn't spend 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 Programs now 21 on any other basis than what they have done in the past. 22 We have asked you, and you have, I think, reviewed them not 23 on the basis of what kind of money might be available, but 24 rather on what they are merited in terms of support. We Federal Reporters, Inc. 25 have tried to keep separate limited funding irom'the quality 30 I of the program. We should also keep separate more generous 2 funding from the quality of the program. It should be review 3 on the basis of the merits of the RMP and the way in which it 4 is consistent with the review process, with the mission 5 statement and the directions in which RMP's are now going. 6 DR. BESSON: Again the legislation says something a 7 little different than that statement of a year ago, and I am no6,. 8 sure how this 140 million dollars jives with these two 9 statements which seem to be somewhat inconsistent. The 10 legislation asks for support of programs that are in line 11 with improvement in the care of heart disease, cancer and 12 stroke first,, and also not as an afterthought necessarily, 13 but maybe as a political statement, include something which 14 has been expanded to be the new mission. 15 1 am still not sure then as I review a program 16 whether any programs that are not in line with the objectives that 17 were articulated a -year ago, whether those programs should 18 be funded. 19 Now eight months ago this came to a head in this 20 committee when as a matter of testing the waters I was 21 reviewing the Iowa program -- excuse me, Miss Kerr, but we 22 will get this out in the open I was reviewing the Iowa 23 program and asked that the Iowa program be denied completely 24 because it was inconsistent with the new mission of RMP even thoug 'edetal Reporteis, Inc. 25 each of the new programs were meritorious. The Review Committee I upheld that position and passed it up to Council. Council 2 reversed the Review Committee decision, and the message that 3 I got from Council at that time was that this was an 4 inappropriate ar-tion of the Review Committee. Maybe in the 5 intervening eight months the entire emphasis of RMPS has 6 changed. Were that action 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 program 9 in light of this statement. 10 DR. MAYER: Let me just emphasize that one, Harold, 11 because I just blew all of last Sunday going through that 12 exercise myself in another frame of reference, Jerry, in 13 terms of legislation,,and what I assume -you are calling our 14 RMPS mission statement was that rather length- letter that y 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 in various devices and it does get a little fuzzy in terms 20 of what really is being said. And the thing that got to me 21 was the very point you are amking. 22 In an attempt to try to get some clarification of 23 this I went back to the new law, and all that did was serve 24 to confuse me even further in terms of where we are. And -Fedetat Reportersi Inc. 25 1 think we really do need some clarification here on this 32 I one and what are you intents also about a more explicit 2 statement than the one that has already been produced. 3 DR. MARGULIES: Well, I suppose the best thing I 4 can do on this is to paraphrase what the Secretary said and 5 which I think is a valid statement, 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 Committee as 8 year I described the kinds of directions for RMP 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 I I 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 picks out one part 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 ranges of distinction, and I am not convinced, although I 21 would like to hear 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 are talking about whether 24 it should be a program as it was three years ago rather than Federal Reporters, Inc. 25 as it is at the present time, because there has been a I 33 I significant change in what the RMP's are doing; there is a 2 movement in the Regional Medical Programs toward the creation 3 of a more effective kind of goal, 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 RMP is like every 6 other RMP, and I think that those kind of differences can 7 continue. 8 So far as the Iowa program is concerned, Jerry, that 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 DRO BESSON: Say that again. 13 DR. MARGULIES: The change from the Review Committee 14 to Council was a change in perception of what the program 15 represented. 16 DR. BESSON: I thought our decision here represented 17 a statement of principle,, namely that, at least as I phrased 1 8 that resolution, we were testing the Councills intent to 19 fund only programs that were in line with new mission. Seems 20 to me that that particular program, the kinds of things that 21 they were asking for were still on the old model, and that 22 this might have been a good test. But maybe we chose the 23 wrong test. 24 DR. MMGULIES: That was just a matter of professions Federal Reporters, Inc. 25 disagreement. DT. MAYER: Dr. Brindley. 2 DR. BRINDLEY: I would like to ask a question and 3 make a comment if I might. I have a disagreement 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 meet those needs and how they would utilize 8 money to improve health care. The question would 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 what they need and how it will apply to 13 them?' We don't seem to determine it. Does the Council 14 determine it? Who does determine that? 15 DR. MARGULIES: 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 Council 19 will review programs and it will make recommendati ons to 20 the Secretary. The decision about grant awards -- the 21 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 time to another of what 24 represents the major goals and objectives of the government Federal RePDrters, Inc. 25 in the development of budgets-and in expenditure of funds I of its program , and that is a part of the general political 2 process. Now whether that is right or wrong is something 3 that I don't believe I am competent to judge. 4 DR. BRINDLEY: Let me ask you one question concerning 5 the HMO'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 some 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 wav.because for tiem 11 another.mot hod is better. 12 DR. MMGULIES: Not I think that is a perfectly clear 13 point. Letts be specific about something like the aith 14 Mainto nance Organization which is somethingthat the 15 administration is keenly interested in. There is no constraint 16 upon a Regional Medical Program to get itself deeply involved 17 with HMO'S. If they say that they think we can 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 reviewed 21 last time is the Ohio Valley IUIP %,hich you are familiar with. 22 Their concern has always been concerned with the improvement 23 of ambulatory medical care and with an emphasis on better 24 uses of health manpower,, and they have not covered a lot of @volteis, Inc. 25 other activities, that they say for our part of the country 36 that is the best thing. If you measure 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 RMP were 7 to provide transplant facilities in as many hospitals as 8 possible over a short period 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 we 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. BRINDLEY: If Ohio Valley says they can do 16 the best job in this manner that is all right? 17 DR. MARGULRES: That is the main purpose of the 18 program. 19 DR. MAYER: Mr. Hilton. 20 MR. HILTON: I just wanted to say prior to what 21 has just been said the suggestion perhaps that there needs 22 to be better communication between the Executive Branch that 23 articulates national goals and the local regions. Part 24 of the reason that my recent site visit was agonizing was -Federal Reporters, Inc. 25 because we ran into the situation the Jerry and others have 37 identified where people were in effect 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 we 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 us,what it is 8 that needs to be evaluated, and give ratings and what 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 is we are 14 evaluating for,, and I just echo his point. 15 DR. MARGULIES: Well, I think that is a very 16 valid criticism. I think we have been inadequate in 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 1 21 have described in the review cycle this is being done very 22 inadequately, and I see little kirA of relief from it unless 23 we are able to lessen the demands of the review cycle, which 24 is one of the reasons for going on a three time a year basis. -Fedetat Reportefs, Inc. 25 The people in the Operations Division, people in 38 I the Professional and Technical Divisionp are so heavily involved 2 with the activities which are now consuming their'time that 3 that aspect of it which is -- really the way to communicate 4 is to be with people and talk with them and to examine what 5 they wish or what they think needs to be done against what 6 their understandingis of what should be done, is essential. 7 And yet we do have a real limitation on how much we can do 8 about that. 9 MR. HILTON: Once that kind of communication and 10 dialogue is under way then will staff be communicating these 11 local needs and concerns to the appropriate people? 12 DR. MARGULIES: That is our intent, and, of course, 13 that is one of the reasons that we worked So hard, and we almost 14 were unable to do it, to get Dr. Duval and to get Reeso to 15 the national coordinators meeting, 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 Medical Programs, but also 18 to answer the kinds of questions which the Review Committee 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 would be most dishonest if I said that -Fedetat Reporters, Inc. 25 I was. 39 I DR. MAYER: Harold, one of the questions which I 2 asked which got lost which 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 RMPS mission, 6 goals, objectives? 7 DR. MARGULIES: 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 ago and 65 percent of 13 them had not even looked at that mission statement, So, you 14 know,, we can do it and we will do it, but it is going to 15 require a great deal more'than that. 16 DR. MAYER: It is very, very important for us that 17 have re ad it five times and still don't have a clear picture. 18 1 think,, you know, you gear your educational program to the 19 bright ones in the class as well as those that are moving 2 0 along slowly. 21 DR. MARGIJLIES: Well, I can say this about it. I 0 22 like the way it was written in the original form. 23 DR. MAYER: Ali I was commenting was that there are 24 some of us who didn't, and we would appreciate some-- Federal Reporters, Inc. . 1 25 DR. MARGULIES: No, I don't mean that form; I mean 40 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 Committee 5 operates has been very elusive. The way the Council reaches 6 its decisions -- I have used the term capricious before, and 7 1 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 somewhat chary about 10 ordaining how RMP 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 Committee 14 are left in a double bind. 15 On the one hand we 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 priority 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 new 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, and they grasp the straws that emanate from Federal Reporters, Inc. 25 this center when they see the mission statement, and I see 41 1 it quoted very widely, because there is very little guidance 2 they have from the center. 3 The Review Committee I think is left in the same 4 position. Even after having served on this Review Committee no# 5 for close to three years I am not sure that I understand what 6 1 am doing and how I am supposed to be doing it; and in that 7 candid statement I think I must say that others on the 8 Review Committee and Council, lot alone the coordinators, 9 must feel in the same position of trying to grasp atclouds 10 and not quite sure whether what they are doing is appropriate. 11 So I again make a plea for some frequent.articulbtion 12 of what it is that we should be up to, or telling them what 13 we are goingto do and how to go about it within broad 14 guidelines and Let the area choose its own modus operandi 15 within those broad guidelines. But these guidelines are 16 necessary again and again. 17 MISS KERR: I think what we are generally saying, 18 we are floundering somewhere, and Jerry just said let alone 19 the coordinators -- and while my information came to me 20 very.informally, I think it is the appropriate time to bring it 21 out, I think the coordinators are floundering. Some visits 22 1 have made and have heard others have made, there were 23 comments "when you Feds make up your mind," actually from 24 the group as we visit them. So they, too, are feeling :e-Federat Reporters, Inc. 25 anxious about this. 42 I My understanding is that the coordinators have 2 employed an attorney. The source of the funds I don't know. 3 One wonders. But for what reason, I would 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. MARGULIES: The only one that I am acquainted 7 with is the fellow who serves as a secretary to the Southeast 8 area coordinator group. Presumably the fact that he is an 9 attorney is incidental to his general organizing 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 Programs. 14 What he does is help convene metings and help develop common 15 programmatic concepts among the Regional Medical Programs in 16 the Southeast area. 17 DR. MAYER: Leonard. 18 DR. SCHERLIS: ',I would suggest that they could better 19 put these funds into getting a psychiatrist. 20 (Laughter.) 21 I didn't want Dr. Besson's comments to go further 22 uncommented 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 day at Fedetal.Reporters, Inc. 25 these Review Committees because I am reminded of "of ?Aice and 43 1 Men," there are two characters, George and Lennie, and 2 since my first name is Leonard I have some feeling for it. 3 Lennie is rather simple-minded. In fact, he has some cerebral 4 impairment. 5 DR. MARGULIES: Bigger than -you, though. 6 DR. SCHERLIS: Much bigger than I. But for assurance 7 he always asked Gorege to tell him about the rabbits and then 8 he fools better; and it is always nice to have Hal tell us 9 about how the review mechanism might work. 10 I do have a great deal of concern because frankly 11 when I go to some of the regi ons 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 feeling abdominally that is good 17 or bad, and then I translate this, as I will today, into 18 specific funding recommendations in 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 I am getting increasingly impressed with the 22 similarity of goals and objectives in the regions, and I 23 could be naive and assume that they all openly define t 24 ultimate truth simultaneously which doesn't really seem to be -Federal Reporters, Inc. 25 realistic. or else the realistic thing is that they know what 44 I the goals and objectives are, because if I put out my hand 2 frequently enough with the wrong bottle 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 whe ther it isn't really 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 merely that the smoke signals 12 have become denser and denser from the spot from where they 13 emanate. 14 1 do have concern now that we again are talking about 15 defining goals and objectives and now that we are adding 16 what are really tremendous challenges -- AIEEC'S, as 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 bed last night and I awakened not 22 any clearer in my own mind, though very often sie ep does 23 have benefit. I am increasingly confused about the goals and 24 missions of RMP, particularly how they get translated into Federal Reporters, Inc. 25 the field, how we can sit here and decide how these funds I 45 I can best be expended. 2 1 hope that as 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 field working and tr-yingto reach an 6 important decision how we can put into clear focus some 7 of the priorities that are obviously required. 8 DR. MAYER: Let me raise two quick points, Harold, 9 and it relates to AHEC's because I think that g ves us an 10 example of two issues. You talk about a combined effort with 11 the Buroeu. 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 putting in? 14 DR. MMGULIES: At the present time approximately 15 II million. 16 DR. MAYER: Then the second question, which gets back 17 to Dr. Brindley'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 feeling of how your document of December 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 about that kind of effort. 24 DR. MARGULIES: The area health education center Fedetat Repotters, Inc. 25 document which will emerge, and as I indicated earlier in I 46 I the morning, is just being completed as a set of guidelines 2 is being developed commonly -- and by that I mean by staff 3 work within review and approval by those under whom they 4 operate, with the Veterans Administration, the Bureau of 5 Education and Manpower Training, the Regional Medical 6 Program Service. And the process that will be followed so 7 far as HEW is concerned is to create a set of guidelines 8 which are accepted both in the National Institutes of Health 9 and the Health Services and Mental-Health Administration; 10 this when it is in a form which is acceptable to Dr. Wilson 11 and Dr. Marston will be signed by them, sent to the 12 Assistant Secretary, to Monty Duval, and if it is acceptable 13 in that form will then be used as the guidelines for the 14 development of area health education centers governing the 15 activities of both Bureau and RMPS. 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-. Let 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 HSHMA, or combinations thereto, which sort of 24 implied to me that there were different kind of labels to -Federal Reporters, Inc. 25 justify the reason for that. And if we are talking about joint I guidelines then I don't understand why there isn't a joint 2 pool of money. 3 DR. MARGULIES: Simply because the funds have been 4 appropriated by different processes for different organizations- 5 and the best 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 AMPS, 10 and I dontt think those differences have been completely 11 resolved, and I agree that that is an unsatisfactory 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. PARKS: 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 outi And 19 second lyt it would require me, I think, to compromise a bit 20 with intellectual honesty. 21 For example, I am concerned about the overall civil 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. I)o we really know about -Federal Reporters, Inc. 25 it? In terms of our evaluation sheet, which is fairly 48 specific,, we have minority interests here which is rated-7, 2 1 guess, in terms of weight. Yet in terms 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 11 herehonestly and openly. 12 I am not sure, for example, from my review of these 13 papers and from the one site visit that I have been on, which was 14 not terribly helpful, that there is an equal employment 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 Programs themselves. I am not 20 sure what it is in terms of so-called staff administration, 21 what instruction do they have. Are the instructions of 22 the Secretary of HEW in fact being carried out? 23 And let me give you an example. I have here a letter 24 from the Secretary, and it is a letter addressed to me, and Federal Reporters, Inc. 25 this will give you the kind of example that really creates a I 49 tremendous problem. And we are talking about money. Money 2 is it. Health, everything else revolves around money. This 3 is a money system. We are talking now 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, 1971. It is 7 addressed to me. It is from Elliot Richardson. It says: 8 "Dear Sir: 9 "It has been the policy of the federal government 10 to encourage and promote the development of minority owned 11 enterprises.In conjunction with this policy the government 12 has intensified its efforts to increase the deposit 13 of funds in minority banks. These institutions are themselves 14 small minority enterprises with most of their commercial 15 accounts being other minority business heads. We should like 16 to encouIrage 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. Stimulation of minorJty 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 RMP'S? Is it a part of the process that -you go through in 23 reviewing these RMP'S? 24 1 take this as a specific kind of example. I just -Federal Reporters, Inc. 25 happen to have this in connection with something else. :)u There are a number of other kinds of directives that 2 have come down that pertain directly to the dispensation of Is 3 federal fundsi and I am not so sure here with the guidelines 4 what role these things should play, whether we should continue 5 to participate in the further extension of these Rinds 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 I I people and that we pass on? 12 1 mention it here, and I think it ought to be out 13 openly and honestly. 14 DR. MARGULIES: Let me answer the specific issue 15 which you raised, the Secretar-y'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. We have, as I indicated 19 in the last several sessions, placed great emphasis on 20 equal employment opportunity in Regional Medical Programs 21 aj3 we have in RMPS. 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 Fedetat Repoiters, Inc. 25 stronger issue and identifying it as one of the reasons for 5i I funding or not funding a Regional Medical Program. We have 2 seen improvement. Improvement 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 nonprof ess ional. 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 1 2 get your comments on them. 13 But th-is is an issue which I think has to not only 14 be looked at, but has to be given greater emphasis or we 15 are mismanaging our affairs. 16 Now the other aspect of it, of where the funds go 17 and what opportunities minorities and underserved groups have 18 to gain benefit from a Regional Medical Program, get us into 19 the question of how one is able to utilize RMP funds and 20 what should be the mechanisms involved. I have been t alking 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 -Federal Reporters, Inc. 25 developed that there is a true minority representation, so 52 I that there is a selection of priorities for the community, 2 an identification of what that community wants to get with 3 what it is investing and what is being invested in its name 4 by federal, state and local government. And the Regional 5 Medical Programs should be totally responsive to those 6 identified needs. CHP 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 strong emphasis on minority interests, but Regional Medical 12 Programs and other federal agencies should be bound by it. 13 Not just review and comment; I would favor a much greater 14 authority for CHP, because I 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 agency. It is too much 17 provider dominated, which is the nature of it, and it is not 18 going to spontaneously seek out, and even though it may try 19 it may not do it effectively, those kinds of investments for 20 RMP which affect the.principle that you have been stating. 21 1 would be happy to see this Review Committee pay 22 a much higher level of attention to those issues. 23 MR. PARKS: Well, in terms of what we are really 24 addressing, and this is in terms of focus and the kinds of Federal Reporters, 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 whether they have signed the 8 forms, but whether in fact these programs are doing what they 9 should be doing under HEW guidelines, under 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 which there certainly is neither obfuscation or question. We 14 need not search for these, and the mechanism for providing 15 us with that advice is present and is a part of the establis 16 ment. 17 What I am suggesting to 'you is that I think the re 18 are some things that we could do wit it. 19 DR. MAYER: Further comments? 20 Yes, Jerry. 21 DR. BESSON: I think Mr. Parks introduces a new 22 notion in the review process, one I think we should pursue 23 perhaps a little more vigorously. if these morning sessions 24 are going to be more than psychotherapeutic catharasis I -Fedetat Reporteis, Inc. 25 think they really have to be translated into direct action. 54 1 1 think it is not sufficient for us to platitudinously 2 say that we need greater emphasis on this, and if I read 3 Mr. Parks' comments and the Director's acquiescence to his 4 comments correctly I would like to suggest to the Review 5 Committee that we do take the step 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 Councit's consideration 8 and decision -- that no RIIPS program be funded without 9 prior indication of compliance of that program 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 motion 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. MAYER: I need to have clarification, Jerry. 18 Well, is there a second before discussion? 19 MR. PARKS: I will second it. 20 DR. MAYER: I need to have clarification from staff. 21 1 frankly have been assuming that that in fact was happening. 22 if it is not, then I think the motion is in order. 23 DR. MARGULIES: Jerry, do -you want to comment on it? 24 MR. ARDELL: The only thing I can say is to the best -Federal Reporters, Inc. 25 of my knowledge what we are doing here I think kind of goes I 55 I back to your comment. I don't know the extent to which the 2 desires of the administration are carried out by this 3 Department. And the only notice we have gotten to date is 4 the continuation of what Mr. Parks has just mentioned from 5 the administrator, and we in turn gave that to the programs. 6 1 don't know if we move in this direction -- 1 7 think what you suggested, Dr. Margulies, is that we are 8 independent, we are one show doing this. I don't know who 9 else would go to this extent at this particular time. I 10 think we need to pursue this before we-- 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 the review of the 16 program that I have had for this session I have had no indication 17 that there has been compliance by a reviewing unit with 18 civil rights legislation as far as HEW 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 like to move that this I bb Review Committee request that that compliance be provided to 2 them before they go through the review process. Have you 3 changed your motion? 4 DR. BESSON: No. I haven't at all. I just added 5 the teeth that such compliance be a sine qua non to funding. 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. tESSON: Yes. 10 DR. MAYER: Or do you or do,you not want the 11 assurance that it is there before funding occurs? 12 DR. BESSON: Yes. 13 DR. MAYER: So there are two different levels and 14 two different issues. 15 DR. BESSON: I would like to have the information, 16 but if, the information 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 without it 19 that program not even be bothered to be reviewed. Does 20 that make it clear, Mr. 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 is !-Federal Reporters, Inc. 25 initiated. DR. BESSON: Right. 2 DR. MAYER: That is a different statement than the 3 statement 'you made earlier. That's all I am saying, and 4 1 need to be clear what it is you want. 5 DR. BESSON: That's what I would like. I would 6 like Councills decision on that point. 7 MR. PARKS: He said the compliance report, and that 8 a certification of compliance be a sine qua non, wit ou 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, Jerry, without writing 14 it down, was your request for certification of compliance 15 and adequate review to insure.,,,,;.- the compliance occurred 16 was@a recommendation -you were making to Council so that 17 that had been accomplished prior to any funding. 18 DR. BESSON: And add the additional clause that no 19 funding be considered without such compliance. 20 DR. MAYER: All right, but that still doesn't get 21 at what I then heard 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 frame of reference. 24 MR. PARKS: Well, let's write it down. Federal Reporters, Inc. 25 DR. MAYER: You see the point I am making. The I I 58 I Point I am making-- 2 MR. PARKS: We will take 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 M. BESSON: Well, I would add the third clause 7 that you just stated, that the program not even be 8 reviewed unless such compliance is part of the information. 9 M. MAYER: All right, fine. I just need to have 10 it clear because those are two different issues, I I M. SCHERLIS: Is there a specif ic written directive 12 which is a checklist as far as what is or is not compliance? 13 1 ask this from a sense of naivety of instruction. You 14 have talked about compliance. Is this a written checklist 15 document. Dr. Margulies, do you have such a listing. What 16 would the certification of compliance indicate? 17 M. MARGULIES: No, all grants and contracts 18 of the.federal government require civil rights compliance, 19 but I am not acquainted with any kind of checklist which 20 would determine whether or not that compliance has occurred. 21 For examplei every university which receives 22 federal funds has to have civil rights compliance which would 23 cover a wide range of legislative acts. It is separate 24 from -- what Mr. Parks was also talking about was Federal Reporters, Inc. 25 executive order, which is another kind of, but related, quest on I And I am not familiar -- my own ignorance with what 2 kinds of check-off lists might exist and what kind of 3 measures have bee n carried out to confirm that compliance has 4 in fact occurred or prove that it has not occurred. 5 DR. SCHERLIS: 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 t s 10 country. 11 DR. SCHERLIS: Could you amplify that, because that 12 is a very interesting response which I didn't anticipate. 13 DR. PAHL: Let me not comment as Deputy Director 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 been in the 17 federal government for ten years, and I am not sure I know 18 what does and does not 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 daresay that I don't know a single community -Fedetal Reporteis,'Inc. 25 in the country that fully complies with the civil acts and I I regulations,, civil rights legislation of the country. I am 2 sure such communities 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 awarded 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 at 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 see what occurs. 18 What I think we 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 schools 21 in the newspapers, it has taken many, many,years,and we are 22 still not at that point. I don't see how it is possible for 23 RMPS in the next three months to achieve national compliance 24 with civil irghts legislation. -Federal Repo( ters, Inc. 25 1 am not in disagreement with the goal. I am trying 61 I to look at it from a very 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 saying 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: But, Dr. Pahl, perhaps some of us 11 neither share your diffidence nor 'your semantic 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 that 14 it is going to take some tooling up. I think that if we 15 hold the purse strings -- and I suppose we do as a review 161 committee, as we really are a polic-ymaking 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 1 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 -Federal Reporters, Inc. 25 reassure me-- 62 I DR. MARGULIES: May I respond to that, because the 2 Review Committee is not a policymaking body. The Review 3 Committee is created as an administrative device to support 4 the activities of the Council, The Council is a policymaking 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. hL4RGULIES: Certainly, but that is not the same 12 as being a policymaking body. 13 DR. BESSON: No, no. 14 DR. MAYER: Sister Ann. 15 SISTER ANN JOSEPHINE: 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? What steps are taken to review the 19 degree of compliance? 20 DR. PAHL: In our program to the best of my 21 knowledge none are being taken. Perhaps staff can mofidy that 22 comment. Jerry. 23 DR. ARDELL: Except to the point that there is a 24 published list of thoe organizations that are in compliance, ,-Federal Reporters, Inc. 25 and if they Are not in compliance we are informed and we do I 63 I not make grants to them until they are in compliance. 2 DR. MARGULIES: I think one must 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 week 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 HEW, it is a part of DOD, and the civil rights review 11 and enforcement activities are of tremendous political @12 prominence, so it could hardly escape one's attention. But 13 we are a part of the HEW civil rights compliance activities. 14 SISTER ANN JOSEPHINE,: I raise this question because 15 1 know that we have many, many fine -- ju§t as in any kind 16 of business, we have many, many very fine policies, but uni ess 17 there is surveillance of the implementation of the policies 18 their formulation may simply be a political move. And 1 19 think that as we are looking at Regional Medical Program 20 services we need to ask whether we feel at this point in 21 time that we are looking at one of the weaknesses of the 22 program when we say we have a policy that applies not only 23 to this program, but to every federal program that is being 24 funded, and yet we are not exerting good management !-Federal Reporters, inc. 25 supervisory control to see that the policy is implemented. This is as I interpret the question. 2 DR. PAHL: I would like to agree that we are not 3 exercising the degree of management 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 12 of the government than ourselves in a very practical sense 13 because society is interrelated and we can't do everything. 14 Again that is not to say that one is is disagreement 15 with the goals. But I think Mr. Ardell would agree that 16 every grant and contract that emanates from RTIPS has many 17 conditions attached, and in ail honesty I don't think any 18 of us in this room can say that we provide surveillance over 19 most of the conditions under which we make the grant and 20 contract 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, e c. 23 1 do not see us in practical terms having the 24 wherewithal to carry out what- the Review Committee is -Fedeial Repoiters, Inc. 25 suggesting, however desirable' it may be. 65 DR. MAYER: Dr. White. 2 DR. WHITE: I think this kind of resolution clouds 3 our role. I think we are mixing up what our purpose in life 4 is and what the purpose of other people might be in 5 reference to this particular point. And it puts me 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 act ng 11 as a policeman, which is what we are trying to do. 12 DR. MAYER: John. 13 DR. KRAWLEWSKI: 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 thi nk one of our real problems is 16 trying to determine the role of this committee here. If 17 we see Council as a polic-ymaking body and then we 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 programs 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 we Federal Reporters, Inc. 25 recommend, because we look at the capacity of a region, we 66 I recommend the level of funding that we believe they can 2 handle. In many 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 6 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 with 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 money 14 out. 15 If in fact you are acting in a capacity where you 16 believe that these regional offices should be very closely 17 aligned with your central staff here and that -you have specifi( 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; Federa I Repor te rs, in c. 25 if you wish, and parcel out the money on the basis Of 67 I specific things 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 awarded grants to all programs at the levels which have 9 been approved by Review Committee and approved by Council, 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 decision -- 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 review 17 process that we have available. 18 Now the next point that -you raised, of having some 19 kind of a process by which we determine conformity versus 20 something which determines whether or not this program 21 represents an effective institution for the region, is one 22 that represents the range of differences which we see here 23 present. Len was saying that he sees programs coming up 24 with the right words, they parrot the kind of sounds which are -Federal Repoftersi Inc. 25 being made at the national level. It is my belief that if 'you 68 then follow the general statements which are made 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 andwe would be deciding in the Parklawn Building what should 5 be done in every Regional Medical Program. I don't think we 6 have that ability. I think it would be a sad mistake@ and 7 I guess the real difference lies in how general our description 8 of goals should be and how within 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 new institution in 13 shifting times and with heavy demands being placed upon us, 14 works remarkably well. I think if you were to set up a 15 different kind of system which is analytical and careful it 16 wood come out very close to the kinds of determinations 17 which this review committee is making. If we get very explicit 18 about it then we might just as well switch to some kind 19 of formula grant and see if the program is doing 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 Program. 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. We can simply make the -Fedeial Reporteis, Inc. 25 grant awards to the project directors and carry it out in a 69 scattered f ashion. 2 Somewhere in between is a structure which manages 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 RMP does or what other federally supported activities do, 16 then to have a strict kind of description of what RMP is 17 based upon that as a theory, when the fact is that B 18 agencies and A agencies are highly variable, would be a sad 19 mistake. I can point'out areas for you, and you know them, 20 too, where there is a powerful B agency in an RMP. And I 21 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 here. Federal Reporters, Inc. 25 It is not a program-like a university which admits I so many people, graduates so many people. It doesn't have 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 forming 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 honestly without that input, 11 including all of the differences which we have this morning. 12 DR. MAYER: We have a motion that is on the floor. 13 Let me see if I can recapture at least, if not the precise 14 wording, the intent of the motion -- 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 Medical 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 21 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? -Fedetal Repoiters, Inc. 2,5 DR. BESSON: Yes. DR. MAYER: Okay. Further discussion of the motion? 2 DR. WHITE: I wonder if the originater 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. MARGULIES: 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 HEW, yes, for all of PEW. 13 There is in education, there is in health, there is in 14 we JLf are. 15 DR. BESSON: Then I would ask that the application 16 be presented to the Review Committee with the definition 17 outlined by that group. 18 MISS KERR: Maybe I am getting to a simplified 19 version of this, but a ball park figure -- and as I have 20 been reviewing regional medical programs, 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 on. Federal Reporters, Inc. 25 MISS ANDERSON: Includes females, too. 72 MISS KERR: Well, I can't argue that. You know, 1 2 don't have much -- but, for example, 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 6 represented. So this is the way I have been measuring. 7 DR. MMGULIES: Well, you realize that this would 8 have to include compliance oh the part of the grantee'agency, 9 which means that every'university, every medical school, every 10 state society which is responsible as a gran ee 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 i so, 0 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 Fedeial Repof ters, Inc. 25 meaningful way in this process so that proper certification I could be done in keeping the review cycle and process-- 2 DR. BESSON: Well, Dr. Hess, I am sure that we could 3 discuss for another week the reasons why 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 as a review 8 committee that this question is considered by Council; and 9 maybe the details make it impractical, but this is a 10 question that we are discussing, whether the weights that are 11 assigned here for judgment of the ranking of an individual 12 region could not have minority interests changed from the 13 weight of 7 to a weight of 16 as a sine qua non. That is 14 all. Now that may be impossible to implement. But if that 15 is the case then staff will have to decide that with 16 Council, 17 But I am not being co@y when I say that is not my 18 problem. It really isn't. I am interested in laying out 19 the philosophical.basis for this principle, 20 DR. MAYER: Further discussion of the motion? 21 MR. 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 to the RMP, because really 24 there is no application that can be processed in this -Federal Reporters, Inc. 25 Department that does not comply with 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 t e assurance t at t e 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 am 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, because you are saying either they 24 are in compliance or not, and if they aren't then that's it Federal Reporters, Inc. 25 as far as funding or even consideration of review. And I 75 I would wonder whether or not you could redefine -your motion, 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. SCHERLIS: I was just using your definition of 8 your motion,, and 'you recognize it has having teeth in principle. 9 DR. BESSON: I do indeed. Our only leverage 10 is funding, and unless we can speak with funding we have no 11 voice. 12 DR. MAYER: Further comments? 13 MR. PARKS: Well, I will make one other comment. 14 The total responsibility for monitoring this does not rest 15 with the officer in the Secretary's office that is charged 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 certainly in terms of burden it should e-Fedetal Repoiteis, Inc. 25 represent only a mythical burden in terms of what this staff 76 I would have to absorb. 2 1 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, and 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 All we are asking here is that we come out with a 10 policy position which clarifies what is or what should not 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 the people 14 here, certainly every one of your public officials, including 15 you, Dr. Margulies, 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 simply calls upon them to 18 live up to that oath, calls upon the Council to take a 19 policy which would encourage that. 20 DR. MAYER: Dr. White. 21 DR. WHITE: I think the passing.@6f a reslution of this 0 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 Medical Program proposes attends to the -Federal Reporters, Inc. 25 needs of these people. 77 DR. MAYER: 'Dr. Hess. 2 DR. HESS: I have some 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 which -you are trying to get 7 across, but to say that there would be no funding would 8 be destructive, it seems to me, of many of the good things 9 which are going on in RMP's which are indeed reaching and 10 helping many of the very people that 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 am in favor of what I think is the principle. 14 Now if you want to modify that and say further 15 increments, without 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 Medical Programs., 18 and I do not think that-would be constructive action. But 19 the message that you are trying to get across it seems to me 20 would get there by some further emphasis on this as part of tte 21 review criteria and a modification of the rate at which 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 what is already there. -Federal Reporters, Inc. 25 DR. BESSON: How would you modify it? I will 78 I accept a modification if it is in line with support of the 2 principle. 3 DR. HESS: Something 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 MR. ARDELL: You see, that statement 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 implemented. 14 DR. MAYER: We will take two more comments and then 15 we are going to vote on the motion. 16 DR. SCHERLIS: Are -you telling us that every region 17 states that it is in compliance? 18 MR. ARDELL: Every grant program must be, before it 19 can be funded, in compliance with Title VI of the Act. 20 DR. SCHERLIS: Then%vhat we are being asked to vote on is 21 a modification of this. Do' we investigate to see if they 0 22 are indeed in compliance? Because on the one hand we have 23 written statements testified to by responsible-- 24 DR. LEWIS: I think I share the problem with -Federal Reporters, Inc. 25 Dr. White or that Dr. White articulated very nicely, insofar I think if you vote against 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 two people 6 around this table have meant when they talk about compliance 7 and what kind of details that really means, and I don't 8 know'whether this intent at abolishing one form of prejudice 9 might not actually allow for the exercise of other orms 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 is up for its triennium is one that Mr. Parks or 14 anyone else at this table is questioning in terms of having 15 such a low score in this particular category as to whether 16 it actually is in compliance with the Civil Rights 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 a 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. @IAYER: Dr. Thurman. 23 DR. THURMAN: I think that many of us share the 24 concern of being labeled bigots, and for that reason I would e -Federal Reporteis, Inc. 25 to propose a substitute motion, and this would be to go back 80 I to what Jerry said initially, to propose that we ask,-.the 2 Council for permission to let us as reviewers consider this 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 garbage and we 7 want some officer to investigate. This would be a much 8 more meaningful approach than for us to get hamstrong at 9 the present point in time with a motion that some of us 10 find we have to vote agains t, 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 Mr. Parks could live with four months, having lived 14 with it for X number of years -- to let the reviewers as 15 they go to a place say "what does your statement of compliance 16 really mean, you signed it, what does it really mean," 17 because we still have the obligation as site reviewers to 18 request a compliance visit be made. That is our prerogative a5 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 it stands. So r offer that as a 24 substitute motion. Federal Reporters, Inc 25 DR. BESSON: Welit 1 would be willing to accept indication On if we do have some that as a substitute motion re than Just compliance is indeed 140 2the review form that interested in. think o fIorma. That is really what I am 3Pr determine the accountability of 4we have a responsibility to I don't know that this is being 5a region for compliance- 6done. I don't see it on the portion of the documents that time. And if Such a statement could be 71 reviewed at any incorporated then I would be perfectly satisfied. 8 MR. ARDELL: There is an assurance in every 9 10 application. 11 DR. MAYER: Let Me See if I have caught the it is up to both the initiator of 12 substitute motion then. 13 the motion and the seconder of the motion as to Whether they or whether they will 14 will accept the substitute motion the original motion. SO I gather 15 nott and we will vote on 16 the intent of Dr. Thurmants motion would be that we would ommittee as it council that the Review C 17 recommend to the participates in the review process be encouraged by Council 18 of ter of Council Policy and as an indica.tion 19 as a mat ljcy to give Particular attention in their review of 20 council Po 21 the program, both in site visits and in this COmmittooo to 22 the issue of compliance with the Civil Rights Acto and -- 23 wel.1t I think that is essentially it- DR. TMMMAN: And if-@ question arose we could ask 24 @4 ce - Fedetal Repottets, Inc. 25 for a compliance officer to visit- 82 1 DR. MAYER: 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 DRO BESSON: Yes. 11 DR. MAYER: Is that clear? Is that an acceptable 12 substitute motion? 13 DR. BESSON: Yes. 14 DR. MAYER: Is it acceptable to you, Mr. Parks? 15 MR. PARKS: 'Well, with this exception, I take 16 it that it does not mean that we should really dicker with 17 whether they complied with what the law is or not. I gather 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. 18 21 that-- 22 DR. THUR?4AN: That is correct. 23 MR. PARKS: I will go along with it. 24 DR. MAYErt: Does everyone understand the substitute @ce-Fedetal Repoiters, Inc. 25 motion? 83 DR. SCHERLIS: Could you please repeat it? 2 DR. MAYER: Well, let me try it again. That 3 this Rev ew Committee is recommending 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 Act, 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 KERR: There was also an added stipulation, 13 wasn't therei that if the reviewer felt-- 14 @D . MAYER: Oh, 'yes. And@ if in fact the reviewers 15 felt that there was some question of compliance that they 16 would have the right and responsibil ity to request that 17 appropriate review of that issue occ 18 Does that catch it? 19 DR. THURMAN: Very good. Fine. 20 DR. MAYER: Leonard, does that clarify it for you? 21 DR. SCHERLIS: (Nods.) 22 DR. MAYER: All right, further comments? 23 MISS KERR: Question. 24 DR. MAYER: All those.in favor of the substitute Federal Reporters, Inc. 25 motion?' (Chorus of ttayes. It) 2 Opposed? 3 (No response.) 4 All right, let me say that I Would like to now 5 welcome Mr. Robert Toomey on board. I hope that you weren't 6 holding back because of newness. I can assure -you that that 7 will wear off very rapidly as we go along. 8 Let's take a 20 minute break or so for coffee that 9 Leonard asked for a half hour ago. 10 (A recess was taken.) 11 DR. MAYER: I think we have gotten the audio back 12 on across the table. We haven't been able to do anything 13 yet about the heat situation. We have left the two doors 14 open. Does anyone have any concern about that? 15 1 would like to move on to the kidney disease program. 17 'MR. HILTON: Mr. Chairman, if I may, could I just 18 interject one thing before-- 19 DR. MAYER: Yes. 20 MR. HILTON: I would just like to make a motion. 21 1 think in our capacity as being advisory to the RMPS staff 22 it might be appropriate for me to make this motion, and by 23 way of doing so just to briefly for a couple of moments 24 revisit the topic of discussion earlier with regard to -Federal Reporters, Inc. 25 minority interest. Someone had raised the question of 85 I compliance and what it meant and whether or not there was in 2 existence a checklist. To my knowledge there isn't. There 3 is usually a glowing statement somewhere that suggests 4 really a spirit document, the spirit of the law being such and 5 such; and I suspect that you can trust under the motion that 6 was passed just before we broke that some reasonable 7 efforts will be made to insure enforcement on that. 8 I would like to approach that angle from a different 9 point of View, something that we can do locally on the staff 10 if we are so inclined. We found in my state of Illinois 11 that we talk about the spirit of the law and the spirit of 12 compliance, people are best able to respond to that 13 effectively if they have the self-interest, the personal 14 self-interest, the determination, and creativity to look around 15 and see what it is they need to do to comply. It is often 16 a situation, as someone mentioned earlier, nice people who 17 simply haven't thought of this or overlooked some things 18 that they could do. 19 In response to that problem locally in our own area 20 we pulled together what really might be considered a kind 21 of brain trust, of people who have the interest, the 22 determination, the creativity to put special attention on this 23 particular problem area. They advise us as to how we might 24 best go about complying as a free consultant kind of service Federal Reporters, Inc. 25 to the organizations and the various publics we serve, and I I 86 think that might help the problem, if there are people who want 2 to comply with the civil rights legislation but quite honestly 3 don't know how, and what for very understandable reasons 4 wouldn't know how. It doesn't necessarily affect them; as 5 our society runs right now most of the people who comprise 6 the establishment are not the people this compliance was 7 designed to benefit. 8 I wonder if it might not be appropriate for RMPS 9 to consider,the possibility of incorporating in its overall 10 operations a kind of brain trust, an advisory kind of group 11 'of this sort, subgroup, that relates specifically to this 12 issue; not an enforcement body -- I would stress that -- but 13 really an agency that reviews or looks at the various programs 14 and their needs and makes suggestions to those coordinators 15 and RAG groups as to what might be done in their particular 16 locale to make them relate more better to the Indians or 17 chicanos or whoever happens to comprise a good bit of 18 their constituency. 19 DR. MAYER: Leonard. 20 DR. SCHERLIS: If I could respond by asking a 21 question. Are you impressed with the good results of the 22 brain trust in Illinois? And I don't want you to go on record 23 as answering it, because the RAG of Illinois has 4 of 47 24 who represent minority groups, and looking at just the sheer -Federal Reporters, Inc. 25 data, having shared the site visit in Illinois, I would not I 87 suggest that this would be the route that might be the most 2 successful to contemplate for the rest of the RMP'S. 3 MR. HILTON: I might suggest I wasn't talking about 4 the RAG of Illinois. No, I was talking about our own 5 educational-concerns in Illinois. I am quite impressed in a 6 negative kind of way with our own -- no, we would like to 7 do this with the RAG of Illinois. 8 DR. SCHERLIS: I was just wondering how we were de- 9 fining success. 10 MR. HILTON: Right. 11 DR. MAYER: I think this is a very appropriate 12 suggestion. What we have done from time to time over the 13 last umpteen years now, we have made suggestions to the 14 staff relative to those kinds of things that they could do 15 that would be helpful in the process, and staff has consistently 16 been responsive, I think, to those needs. I think the 17 message has been heard very clearly as a suggestion in relation- 18 ship to how you go about implanting if the Council accepts 19 our proposal. 20 Now I would like to move on then to the kidney 21 proposal. Dr. Hinman. 22 DR. HIN?4AN: Thank you. I will follow the order on 23 the agenda,, although it is not necessarily the order of 24 development of activities in the kidney program in the -Federal Reporters, Inc. 25 Regional Medical Programs Service. 88 I At your last meeting you posed four questions to 2 Council,by resolution, and I will report back their answers. 3 The first question was whether the Council recommend 4 that money apportioned for renal disease be considered in a 5 proportional ratio to the total amount of money of the RTIPS 6 budget. And the Council answer was no. 7 The second question was whether the total amount 8 of money-- 9 DR. MAYER: Wait a minute. Slow. Maybe we better 10 make sure we have got that one. Let's take them one at a 11 time. 12 DR. HI Well, the first two are really almost 13 one question. That's why I was going to it. 14 DR. MAYER: All right. 15 DR . SCHERLIS: Can we turn off that clicking sound? 16 we have enough static as it is. 17 DR. MAYER: Why don't we go on, and we will try to 18 get at that. 19 DR. HINMAN: The second question was whether the 20 tot.al amount of money spent in a given region for renal 21 disease should be in proportion to the total amount of dollars 22 being spent in that region. Now the answer from Council 23 to that was also no. The philosophy -- well, principle here 24 being that we are not a categorical program nor is money Federal Reporters, Inc 25 allocated by Congress or apportioned in a totally categorical 89 fashion, nor is it our desire to become a categorical program 2 again in the narrow sense of the word. And this was what 3 lay behind the answers to those two questions. 4 DR. MAYER: Are those two clear? You all have 5 a copy of the questions now. Comments on those two? 6 SISTER ANN JOSEPHINE: Are we running into a 7 problem -- I know if they say no the answer is no, but I would 8 like to raise a question. On number two it would be possible 9 if there were a group who could really push through proposals 10 for renal projects in an area where maybe the amount of money 11 allocated to the program would not represent an allocation 12 commensurate with the needs in the area, and that would be 13 the thing that concerns me. 14 DR. HINMAN: We are very concerned about this, and 15 when I talk about our new proposal for the review mechanism 16 for kidney disease, which is item number five on my list 17 assigned, it will come to that. But we are concerned that 18 kidney not be necessarily the dominating part of any one 19 program. 20 However, the point was made that the treatment of 21 in stage renal disease requires a coordinated, cooperative 22 effort of various providers throughout a region, and if 23 agreement or cooperation can be secured among these providers 24 in the area of in stage renal disease this might be a Federal Reporters, Inc. 25 mechanism of bringing the region into a regionalized approach to the treatment of other patients and the handling of other 2 health care issues. And I think that that is a valid point, 3 that there are regions in which the nephrologists and 4 transplant surgeons may be further along and they are being 5 willing to cooperate between institutions than other types 6 of providers. 7 So that Council discussed the very issue that you 8 have raised Sister, and because of the tremendous cost of the 9 resources in in stage renal disease, but felt that we should 10 not take an arbitrary position either way, but handle it on 11 the merits of the individual region and their total program; 12 not projects, but their total program. 13 DR. MAYER: Okay, third question. 14 DR. HINM: The third question was whether renal 15 programs funded by the regions 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 budget dollars When it goes back to them in the advice 19 letter. Confusing? 20 In other words, if region X has a kidney program 21 approved for $50,000 and their.total budget is two million 22 dollars -- their total budget is two million dollars, then 23 the fifty thousand has to come out of it. In other words, 24 the total award includes the kidney dollars. e - Fedetal Repor teis, Inc. 25 DR. MAYER: Do they have the same degrees of freedom 91 I with it after they get it that they have with the other? 2 DR. HINMAN: You mee-n-in the anniversary triennium 3 sequence? 4 DR. MAYER: Let 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 reviews 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 millic I 1 dollars in it and we only approved half, can they take 12 that half million dollars of renal money and pump it into 13 something else, or have they got to pump it into kidneys? 14 If you excuse the pun. 15 DR. HINMAN: I really don't know the answer to 16 that question. 17 DR. MAYER: Well, it is an important question. 18 DR. HINMAN: The question that was asked, Herb, 19 was can a regiIon 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 100,000 out of that 23 back into other program areas. 24 DR. PAHL: I think we would want to have a request @f,- Federal Reportets, Inc. 25 for approval come in to RMM for a major change like that. I DR. HINMAN: is that any different from any other 2 major program change? Now let me -- it is different. Maybe 3 DR. MAYER: und rules. AIJ the question 1 4 r don't understand the gro send it 5 am asking, Herb, is when we send back an award we 6 back with some advice and then We delete some projects, but t of the projects, et cetera, 7 in essence we usually approve mos 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, this'is how 12 we are going to spend the two million dollars and 'you 13 allocate it. And 'you say okay, sign 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 anything else. 19 DR. PAHL: Jerry is shaking his head. He may have 20 sow personal experience. 21 MR. ARDELL: Not really personal. I was think ng 22 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 Federal Reporters, Inc. 25 to kidney into something else I would think that our review 93 I process should at least get the blessings of the director of 2 the service for moving in this direction. I think that is 3 probably open for discussion. But that is the intent of 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 f act. If they are less 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. MAYER: Ed. 14 DR. LEWIS: I'm reassured that the word categorical 15 is considered a vulgarity in these chambers, because@it.@saves 16 me using a lot of other words. The thing that tickled me 17 about the answer from Council was that we had a real problem here 18 the last time and we asked them a question which amounts 19 to "is this pen black or white, 11 and they came 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 !-Fedefal Repofters, Inc. 25 are funded, and I would like to have clarification of that 94 1 specif ic point. 2 1 just wonder if there was someone who was at the 3 Council meeting who is aware of whether 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 already. 6 DR. HINMAN: Well, Ed, as you know, there are 7 certain constraintsupon the allocated dollar that come to 8 R M even though they are noncategorical, specifically the 9 AHEC and the HMO 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 RMPS program 12 and the total request coming in from the regions, a figure that 13 is a fundable figure that is discussed between RMPS and the 14 office of the administrator and the various other parts of 15 the budget cycle. 16 That is a vague answer, but the process is not as clean 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 2^4 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 -Federal Reporters, Inc 25 stage instead of later. I 95 As was stated I think at the last review committee 2 meetings 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 between the 10 state of technology and the delivery in many areasi 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 in 13 a semi-separate fashion. 14 We are working on the guidelines at this time, and 15 they will go something like this. When the renal group in 16 a particular region has an idea and begins to discuss with the 17 local RMP 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 RMPS. 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, 1970 ones, and advise them as to 23 whether the idea they have would seem to be at least in the 24 realm of activities that are appropriate for the limited Federal Reporters, Inc. 25 dollar that MIP has at this time. 96 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 local RMP, the local 4 RMP will be instructed to have a local technical review, 5 it will be recommended that they include experts 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 oC 12 -the RMP program. it will then be submitted to the Regional Medical program Service, at which point my staff will be 14 asked -- Bob Chambliss's staff will be asked for two 15 certifications that will go with it to the Review Committee, 16 i..-e., 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 241 I this committee. -Federal Reporters, 1 25 The second certification would be as to the adequacy 97 I of that RMP to administer the program that is requested. 2 And that gets to the question that I think was behind 4. 3 Sister Annis question, and that is whether this would be so 4 skewing to the local region's program 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 would 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 articulatemy response in the 14 knowledge that I am assuming an attitude of general 15 belligerence and will probably upset a very longstanding 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 amount 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 assistance, but also because 23 it appeared that there needed to be a body that was able to 24 determine more than local activities. That is there had -Federal Reporters, Inc. 25 tobe an overview as to how much kidney activity was going on I around the country or in the areas surrounding a given region. 2 Now it seems to me that what we have done is this. 3 1 honestly believe in view of the fact that RMPS 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 we are now 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 from t 16 outside who are consultants, but they are only consultants. 17 They cannot tell the region -- they can pass some judgment.on 18 whether the technical capability is there, but they canno 19 pass on judgment as to whether 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, 24 but because they would honestly like their patients with -Fede,ral Repottefs, Inc 25 kidney disease to be.in a Cadillac rather than a Chevrolet. I 99 1 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 RMP activities, 8 because all of this has gone on without any indication to 9 myself, or as far 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 programswould come 13 through and be passed on to you on the Review Committee 14 1 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 being that most people who do 17 not have nephr6logy expertise are not willing to pass 18 judgment on these very expensive and highly technical things. 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 I 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. -Federal Reporters, Inc. 25 DR. HIMIAN: Let me respond. There are several luu 1 points that 'you raised. First, my concern is that there be 2 Chevrolets for all the patients throughout the country, 3 not Cadillacs. 4 Secondly,, there are other very technical projects 5 e submitted for review by this committee, and to my that ar 6 knowledge none of them are shunted to a particular specialist 7 or individual because of a particular area of expertise. 8 1 am not sure that kidney should be treated any differently fri)m 9 anything else in that respect. 10 Third, this could all become a very major problem 11 if there were 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 RIAP dollars to go into. As long 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 we are talking 17 about. This was one of the issues 'you all spent a little 18 time on earlier, about communication from this office to the 19 regions. 20 We are concerned -- and that's the topic on the 21 agenda called life plan -- with whether a region has developed 0 22 a plan whereby any patient who is identified ao being an 23 irreversible chronic rendal disease and in impending 24 difficulties, i.e., unable to manage his own self and Federal Reporters, Inc. 25 needing assistance, should have available to him access to 101 care. This care includes medical management as well as the 2 adjuncts of hemodialysis and transplantation when it becomes 3 indicated. However, the costs of this, as Dr. Lewis pointed oul, 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 which will require that the 14 region have such a plan for care of their patients, that 15 the RMP dollars would be used for selected portions of 16 helping them develop the resource, the pieces of this plan; 17 so that with 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 p@itient is a candidate for home hemo- 0 23 dialysis, and if not, whether a candidate for ambulatory cente, 24 which is a lower cost hemodialysis, and as a last resort -Federal Reporters, Inc. 25 institutional dialysis when they reach that point, Dr. Scheriis. 2 DR. SCHERLIS: I admit to being a little further 3 confused than I was even earlier, 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 me@put myself in the position 7 of being a member of RAG, with well 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 giving service 11 to a relatively small group of the population, I would have 12 to evaluate this service in terms of goals and objectives, 13 and I would suggest to you that I Would not support, looking 14 at a priority system, any renal project on a local RAG priority 15 basis if I am to look 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 will 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 look at the overall expanded efforts of RMP. Fedetal Reportets, Inc. 25 Now if I am,alone in this point of view then that 103 1 would be an interesting finding that I would be led to believe 2 would not really exist. 3 I don't think the renal programs would really 4 get the support or the priority rating unless they are given thiE 5 by point of view of specifically designated funds. And I 6 would like to have some reac tion from other members of the 7 Review Committee. It isn't that I am opposed to renal 8 projetts, 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 13 in that regio n at this particular time. This could very well 14 be what would happen, I predict. 15 DR. HINMAN: This is the justification for the 16 continuance of a semi-marking of funds. 17 DR. SCHERLISO. I wanted to ask you what -you meant is by semi-separate. That was the best answer I ever heard to 19 an either/or response. Referring to question three, I expected you to say yes, given that choice# but you said 20 21 semi-separate, and that confounded me further. 22 DR. HIN?4AN: This is the only program in which 23 there would be a partial earmarking of funds. Now the 24 word earmarking or separate funds is a very dangerous Federal Reporters, Inc. 25 phrase. If we start earmarking that a particular category IU4 for one reason or another should be handled by eight million 2 dollars out of 135 or such thing, 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 7 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 Itrying to 13 juggle between the two. That's why I say semi-separate. 14 DR. SCHERLIS: Let's put this on the following 15 basis. We 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, 20 particularly since we feel that the total request is out 21 of line. Therefore funding level is suggested which 22 specifically exclude-- renal. 23 Now what impact does your semi-separate funding 24 have on that decision, because the way that I would suggest '-Fedeial Reportels, Inc. 25 we might go would be back to a national group which is 105 specifically charged with the renal funding and attempts to 2 get some distribution and somesharing of these facilities 3 on a large 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 would you counteract that? 7 DR. HINMAN: 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 wer3 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. SCHERLIS: I'll settle for that, $300,000. 14 Whatever it is we put a red line through. 15 DR. MAYER: The principle is absolutely critical. 16 DR. SCHERLIS: This is what happens when you go out 17 to a region-- 18 DR. MAYER: This is what we asked the Council, and 19 what we are getting back is mush. 20 DR. HINMAN: I have the 20 pages of Council minutei 21 here, the stenotype of them. 22 DR. SCHERLIS: We asked that they answer yes or no, 23 and we can't sa semi-separate. y 24 DR. MAYER: Do you understand the question that Federal Reporters, Inc. 25 he has asked? That is a very important question he has 106 I asked, Dr. Hinman. The question is what happens 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 therD 5 and said that4s 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. HINMAN: 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. MAYER: That's the question we are asking. 12 DR. WHITE: May I make a comment? 13 DR. MAYER: Well, let me just pursue it, because 14 1 have the feeling that if in fact 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 within the 17 total region's activities that's being 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 get a half a mil. Now that's my guess. Now that's 0 23 a fact -- I suspect it's a fact. I see a lot of nods 24 Federal Repo(ters, Inc. going along, just as I saw them when Leonard made the 25 statement, and how are we going to deal with that? 107 DR. WHITE: Seems to me this is inconsistent with 2 what we are supposed to be doing these days. We are 3 determining, I thought, the quality of the region 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. SCHERLIS: 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 worry about this funding, 15 that's a separate vehicle, it really doesn't come out of the 16 total support that we 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 items-- 21 DR. MAYER: And if they know this Review Committee 22 is going to look at it the same way. 23 DR. SCHERLIS: We are changing the whole way in 24 which it is presented. It won't get out of the regions to -Federal Reporters, Inc. 25 got to us is what I am suggesting. I may be wrong in my guess. I 108 1 DR. HINMAN: At the present time, though the RegionaL 2 Advisory Groups are not attempting to relate the magnitude 3 of the renal program 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 was just -- do 'you want to make 7 the comment that you made to me? 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 moment but to follow, is that we are 11 requesting both the region and the site visitors review 12 committee to consider the kidney proposals as a separate 13 consideration from point of view of merit and invoivment in 14 regional activities and in fundingand that these dual 15 recommendations, if there is a kidney proposal and 16 the regular regional medical program proposal, go to the 17 Council where 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 separate and 24 not separate. We have been required to identify for HSHMA -Federal Reporters, Inc. 25 what our level of spending is anticipated to be for kidney io9 projects, and we hope to identify kidney activities at 2 that level by the end of this fiscal year. There is no item 3 within the Congressional appropriation which says that we 4 will spend that much money for kidney. 5 DR. MAYER: What you have just said then, Herb, 6 that it is separate-- 7 DR. PAHL: Yes. 8 DR. MAYER: And we should consider it separate? 9 DR. PAHL: We are requesting that it be considered 10 separate and transmitted to the Council in that sense, 11 where they in fact up to this point, including the last 12 Council meeting, are also looking at the kidney proposal 13 in any RMP proposal as a separate issue, and at the last 14 Council meeting in fact have made separate motions relative 15 to the RMP level of.support and the kidney. 16 Now I am afraid I can't clarify further, and I 17 would suggese that if-further discussion is to occur that 18 we have Dr. Margulies here, because I don't think Dr. Hinman 19 and I can say anything except over and over again what we 20 have been telling you. 21 DR. MAYER: We went through this at the last 22 meeting and spent a lot of time on it, sent it up to Council 23 for a good reason, because this committee didn't know how to 24 act -- 'you know, they just didn't know how to deal with the p -Federal Reporters, Inc. 25 issue. Now, you know, if we are going to wait another three 110 I months to find out how to deal with the issue, fine, tell 2 us. But my assumption was we were going to get this 3 resolved at this meeting so we knew how to deal 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 with what I need as a review 8 member. If we are going to deal with it together, then @9 we will deal with it together, and 'you will 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 KERR: And we have to go 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 while ago, 16 that they take the renal funds and use for another priority, 17 unless it is a separate priority. 18 DR. NIAYER: Ed. 19 DR. LEWIS: Just in answer to your initial comment, 20 1 really would not be so pretentious as to insult the other 21 members of this committee by suggesting that renal projects 22 or their scope are anj more technical than any other project 23 or philosophically are different in any way. I think that's 24 absurd, and I have never suggested that. But what I would Federal Reporters, Inc. 25 suggest is that both historically in terms of Congressional I hearings and in terms of the spirit of why money *as initially 2 given to ]kidney disease, and on the basis of there being is 3 relatively few people involved, and however you want to look at 4 all subjects being equal, I can tell you that the budgets of 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 7 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 way of reviewing 12 things in the interest of decentralization, the politics 13 of noncategorical approach,, and so forth. And right now I 14 am left in a situation where I don't know how to consi er kidney 15 project, and boy, they are coming in in droves, I can tell 'you. 16 DR. SCHERLIS: Would the Chair entertain a motion? 17 DR. MAYER: Well, Dr. Pahl was getting ready to 18 comment. 19 DR. PAHL: Well, in Dr. Margulies' absence I would 20 suggest that within RMPS conceptually 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 -Fedefat Repoiters, Inc. 25 staff reconsider its proposed review process I think that's I 112 1 most legitimate. 2 The best advice I can give you is that we are 3 requesting that you consider the kidney proposals separately 4 because we are into this semi-earmarking 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 1 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. SCHERLIS: I just want to ask 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 has a separate mechanism, or do you 16 want us to say we recommend zero funding, in which case what 17 do you do in RIAPS? 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 face when we go 20 into a region now. What do 'you recommend we do, Look at it 21 or not look at ito 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 --Federal Reporters, Inc. 25 their review to guide you in looking at it. 113 There were two site visits held during the December 2 cycle of site visits in which there 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 thelsite visit teams. 6 DR. MAYER: Let me try to get at the same question ii a 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 regions 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; and when I got to question four from your comments 13, 1 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 obli, a-ion to function, 23 and that's why we sent the questions up to Council four 24 months ago. And I can't be more explicit -- I'm not trying -Federal Reporters, Inc. 25 to be obstinate, I'm just trying to -- tell me what to do, end 114 I by George, I'll go ahead and do it, but donltgive me something 2 that I can't do or I object strenuously. 3 DR. HESS: 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 can cer 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 this 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 the record 19 by saying I will give you the best answer I am capable of. 20 Now I would like to go off the record. 21 (Discussion off the record.) 22 DR. MAYER: 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. -Fedetal Repoiters, Inc. 25 DR. PAHL: Lot me try once again. The Council 115 1 provides a budget to the region which specifies whether or 2 not the kidney activity has been approved in whole or in 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 has 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 RMPS funds, but we identify for the office of the 15 administrator and other units of government 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. PAHL: Well, lot me first try to answer 23 point four, and perhaps Dr. Hinman can read you an appropriate 24 statement from Council. -Federal Reporters, Inc. 25 We in RMP8 believe that the kidney activities from I 116 1 a program point of view should be reviewed at all levels 2 within the total context of the Regional Medical Program for 3 that area. So forgetting funding aside, we are interested 4 in having our own staff, site visitors, review committee,, 5 and Council consider whether the program in kidney activity 6 proposed by the region makes sense for what 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 programmatic sense. yet we must 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. MAYER: But that's where we are on the horns of 14 a dilemma, because you dan't do that. In other words, 15 if you go into a region and you take it within the total 16 context -- you know, what I indicated,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 thereforg- 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 who tries to unlink them is going to 24 end up with chaos. And that's where this committee is, and ,-Federal Reporters, Inc. 25 we have to know whether 'you want us to review that @ a part 117 I of the total program, and including their funding, or whether 2@ you do not. And if -you do, you know, then are are going to take 31 one approach to it', and if .vou 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 would have to state that since 7 we have spent several meetings and seemed all 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 complicated by the history, the political 11 context, and the funding. And yet we are attempting within 12 the concept of a Regional Medical Program to look at the 13 capability of their carrying out what they propose to do 14 and the manner in which they propose to utilize their own 15 staff and funds. And it is a dilemman, it's not the only one 16 we have. Ireally 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. Hinman has 19 it from Council, which is a@@transcript which we will be 20 happy to place before you in xerox form, let you read and discuss 21 further, or re ad it to -you, which is somewhat lengthy, or have 22 Dr. Margulies give -you the clearcut answer, I cannot be of 23 further assistance in resolving the dilemma for you. 241 DR. MAYER: Then we have to resolve it ourselves. Is -Fedefal Repoitefs, Inc. 25@ that what you are saying? We will be glad to do that because, 118 1 you know, we have got to have some 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 thaty I suspect. 4 DR. PAHL: Well, let me throw it open to staff, 5 because I really feel I have failed the Review Committee in 6 trying to do something which which Dr. Margulies apparently 7 to this date has not also been able to do either, Is there 8 anyone in the room that feels that they can state better than 9 1 what we are attempting to accomplish or say it in such 10 terms that we can get off the horn, 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 act and we will respond. 141 I would suggest before the committee takes the 15 action that you permit Dr. Hinman to read what he thinks are 16 appropriate sections which I thin.k we can condense from the; 17' Council transcript, because part of our difficulty is that 18 we are intermediaries and it wasn't that much clearer at 191 Council meeting. So if you would like to have it perhaps it 20 would be helpful. 21 DR. HINMAN: After the lengthy discussion about 0 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 ,-@-Federal Repoftefs, Inc. 25 continue to review on the basis of the merit of the proposal, 119 1 that you are not in the position to determine year by year 2 budgetary allocations; that 'you would like to be in a 3 position, however, to criticize the budgetary decisions which 4 are made and have some accounting of how those budgetary 5 decisions were made; and what you mean by regionalization of 6 being associated with regionalization of kidney activities, that 7 this can be either through an R14P 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 DR. MAYER: That doesn't deal with the issue. 11 DR. HINMAN: I have a pra r-tical 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 keeping the total regional needs in mind. 20 Is that clear? or possible, I should say. 21 DR. MAYER: Well, without having the individual 22 proposals before us -- you know, I was very fortunate in the 23 one I had which had a kidney proposal because I wasn't 24 presented with the dilemma because it did'have ad hoc kidney Federal Reporters, Inc. 25 group report on it, and they voted against it, all three parts 120 1 of it, and so it solved my problem. I didn't have to face 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 Yess Ed. 12 DR. L;EWIS: 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 15 in a uniform way; ergo, I was on the site visit team to 16 Florida, the Florida program was reviewed by me, the budget 17 was reviewed on Itonday here in Washington with the people 18 from Florida and with the propl-e from the kidney program, by 19 myself, and it has now passed up to the review committee. 20 On the other hand, other renal programs have come other 21 ways. Some have come straight up in the manner in which 22 Dr. HinmAn is suggestiii- it should be done in the future, 23 others have come through the ad hoc review panel. d 24 think that this is really highly unfair to people who are @-Fedefal Repoftefs, Inc. 25 applying, and I don't know what the answer to this is, because 121 1 there is a definite need, the money is there, and we have to 2 do something. But I think that this must change. 3 DR. 14AYER: What 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. SCHERLIS: I would suggest that we might best 8 defer all renal projects until we can consider them in a uniform 9 way,, because I am sure that practi cally 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 looking 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 all 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 -Fedefal Reporteis, Inc. 25 literally years evolving well coordinated projects, I don't 122 1 see how we in fairness can compare one region to another, 2 one having a program, the other not. 3 DR. MAYER: What is your suggestion then? Could 4 we then move on to some other parts of the kidney activity 5 and assume that we will get at this head on when we are faced 6 with reality testing. 7 DR. HIMIAN: There were two other points that I 8 wanted to bringto your attention unrelated to review 9 mechanisms. 10 One is that there are a number of federal programs 11 that are involved in various aspects of funding in stage renal 12 disease, and to date the level of cooperation and 13 coordination between them has not been at its highest. We 14 feel that in certain key areas,, three specifically, that there 15 should be a central protocol or some central agreement .as to 16 how funding and support of these areas goes on so that At 17 some point in time information will be available to providers 18 as to what will be the be st thing to do for patients. 19 The three areas @re antil-ymphocyte globulin 20 preparation, HLA typing and its value and necessity, and 21 registry information of both dialysis and transplantation. 22 To this end we have initiated discussions with the 23 ag encies involved to attempt to come out with some sort of 24 common protocol, the most crucial one being antilymphocyte e-Fedetal Reporters, Inc. 25 globulin, because if it does turn out that this is of value 123 in transplantation patients the necessity for the Food and 2 Drug Administration to license it so that there can be 3 commercial production becomes an overriding issue at some poinl 4 in time. So we are trying to get the FDA, three Institutes 5 from NIH, the Division of Biological Sciences, Arthritis 6 and Metabolic Diseases, and Allergy and Infectious Diseases,, 7 the V.A.,, and our group together, and possibly including some (f 8 the Department of Defense activities, because we are all 9 involved at some level in funding. So we hope that from t s 10 something can come forward that will be of assistance 11 in the field of kidney disease 12 The second point is in light of this, and because 13 of some of the other controversy and problems in the area, 14 it is recommended that any project that requests funds to 15 produce antilymphocyte globulin, that review or approval 16 of this be deferred until there is a coordinated strategy. 17 This recommendation wasiaccepted by Dr. Margulies. .18 DR. MAYER: Is that here for our information or for 19 our-- 20 DR. HINMAN: For your information. 21 DR. MAYER: All right. Do you want to comment, Ed, 22 anyway? 23 DR. LEWIS: Yes, I would like to comment anyway 24 that I think it's unfortunate that one of the few things Fedeial Reportefs, Inc. 25 that RMPS can do, and that is fund at least local use of 124 1 antilymphocyte globulin, which I would put out to you is 2 offeective, because I think a panel of experts will argue 3 from now til the cows come home about whether 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 antilymphocyte giobulin for interstate commerce. Never. 10 DR. MAYER: Any comments from staff about that? 11 Okay, we have got a prediction on the record then. 12 Dr. Hinman, any other items? 13 DR. HINMAN: That's enough headaches for today. 14 DR. MAYER: Ali right, I would like to turn now to 15 report from Mrs. Kyttle. She has a couple of issues she needs 16 to point out to you. Lorraine. 17 MRS. KYTTLE: 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 Council from May back-to 21 April, and therefore move committee back from April to 22 March, would the dates-- 23 DR. MAYER: The other way around. 24 DR. PAHL: Move committee from April. to May. Fedetal Reportets, Inc. 25 MRS. NIYTTLE: Right. Excuse me, I'm going in the 125 wrong direction. I'm sorry. Would the dates -- asking you 2 still to keep April 12 and 13 logged for the standing meeting, 3 would the dates of 10th and lith of May be agreeable for a 4 meeting that could be put on the books, and when the thing 5 finalizes we can say whether we will be meeting in April 6 or May? 7 DR. MAYER: Not for me, for one. 8 MRS, KYTTLE: All right. 9 DR. MAYER: I have seen three. Any others? Four. 10 MRS. KYTTLE: To move it up or back in that week, 11 would that help? 12 DR. MAYER: 8th or 9th, 12th or i3th. No. No. 13 10th and lith. 14 MISS KERR: There is a regional conference that 15 has been long scheduled. 16 MRS. KYTTLE: The whole week. May 8 or 9, or 17 9 or 10, some time in that week of the 8th through the 12th 18 of May, two days. 19 DR. MAYER: How many cannot be there on 8 or 9? 20 (Show of hands.) 21 DR. MAYER: 9 or 10? 22 (Show of hands.) 23 DR. MAYER: 10 or II? 24 (Show of hands.) e-Federal Reporters, Inc. 25 MRS. KYTTLE: At the risk of pushing it into 126 1 Councilt is the week the 15th through the 19th better? 2 DR. MAYER: It is not for me since we have 3 graduation and that's one thing a dean doesn't miss, 4 MRS. KYTTLE: The latter part of the wek of-the 5 4th or 5th? And that will put staff on its ear. 6 DR. MAYER: That's better. All right, how many can't 7 be here the 4th or 5th? There Is one. Just one. 8 MRS. KYTTLE: Now thinking of your travel, it is 9 sometimes hard to get out of here on a Friday, which is the 5th, 10 is the 3rd and 4th-- 11 DR. MAYER: How many can't be here the 3rd or 4th? 12 DR. PERRY: 3rd only. 13 DR. MAYER: So that's one and a half. 14 IXRS . KYTTLE: 4th and 5th seems the best. Dr. Pahl, 15 do -you think maybe it might wind up as a one day Friday 16 is darned hard-- 17 DR. PAHL: I think we have to consider a two day 18 meeting, and please understand this is still predicated on 19 our receiving instructions as to whether we are going to 20 be bringing you additional grant applications in the area health 21 education center, and that one is trying to be-decided by 22 the office of the Administrator. It may go con tract route, 23 in which case we may not be compelled to hold the meeting 24 later than the currently scheduled one. So we are asking -1-Fedefal Repotters, Inc. 25 really that you consider a two day meeting in May rather than iZ7 a two day meeting in April, but holding all dates open for 2 a few days until we can try to come back and cancel one 3 of the two proposed meetings. -4 DR. MAYER: Okay,, then let's tentatively hold on 5 to May 4, 5, because even though Friday travel is abominable 6 out of here, if you have got a month's noticeor two months' 7 notice you are in pretty good shape. 8 All right, other items. 9 MRS. KYTTIX,: The green document that we passed 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 shows the specific 16 ratings by the committee, and the items to the right show 17 the staff anniversary review panells conclusions that came 18 out of the last review cycle as well. 19 DR. MAYER: Try me again, 20 MRS. KYTTLE: The box in the middle represents 21 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 reviewed by committee last time. 24 That's the box in the middle. The box to the right are the f@'-Federal Reporters, Inc. 25 rating.s-, that came out of the staff anniversary review panel, 128 1 and you remember last time our procedures, we were 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 tle 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. NIAYER: 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, November cycle came out you 13 could see the differences between the settled rating and the 14 for opener ratings, and that's the difference between raw 15 and adjusted. 16 MR. 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 average it 19 was, if I remember the figures correctly, 301, and the first 20 staff panel was 303, which wasgiven a 500 scale, seemed about 21 right. So we took an adj@sted 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 300. @-Federat Reportefs, Inc. 25 MRS. KY7TLE: This places 27 regions, and next time I we will come to -you with the chart that will add 12 to it from 2 this. 3 DR. MAYER: All right. Other coments? You were 4 going to comment on some discrepancies between Council and-- 5 MRS. KYTTLE: Yes, from the last October, November 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 were 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 to Council from the staff anniversary 14 revie w panel generally were accepted with two slight 15 modifications; Tennessee Mid-South'had a slight modification 16 and New 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. Two 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 Federal Reporters, Inc. 25 turned on Councii's disapproval of the kidney project within I ..that proposal.. and their rationale is there. 2 The rationale on the modification of the Connecticut 3 recommendation is more extensive. You@recall 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. You 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 I I you wish. 12 DR. MAYER: No, I think it is very important that 13 this review committee do understand where it is running 14 counter to the wishes 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 than to try to do it 19 now. 20 MRS. KYTTLE: Attached to -your agenda is the 21 statement about the confidentiality of the meeting and the 0 22 conflict of interest. 23 DR. MAYER: And I think I would only add to the 241 confidentiality a more even explicit feeling that the review -Federal Reporters, Inc. 25 cycle rating sheet which -you have is handled with extreme care, because if in fact there are going to be dollars attached 2 to those, as was suggested at the outset of this meeting, 3 it takes on even more importance that they be handled with 4 exquisite and extra care. 5 @MS. KY7TLE: 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. PAHL: Well, 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 committee 11 representing the coordinators had had an opportunity to 12 comment upon this to us, and over the time period since we 13 last met we have again informed the steering committee of our 14 interest in formalizing this as a part of our total review 15 process and asked for comments again. And then we met with 16 them in Chicago the first week in December and they 17 uniformly endorsed that we proceed with it, and I believe, Pete, 18 a communication has gone out now. 19 MR. PETFRSON: It is in the process of going out' 20 now. The actual letters to the 56 coordinators are being .2.1 put in the mail now. 22 early understood by the M. PAHL: But it is cl 23 e steering committe , and thus all the coordinators, that the 24 review criteria and the ratings, weights, etc., that you have ,e - Fedetal Repoiters, Inc. 25 before you are now part of the RAIPS review process. 132 I should really say that this endorsement by the 2 steering committee was not given in a grudging 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 regions. 7 So there was some degree of enthusiasm voiced at leas 8 by the steering committee members that we 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 on what I I you have before you. 12 DR. MAYER: Could I just ask one question while we 13 are on it? The figures that are there on the RMPS rating 14 sheet which you provided us, Lorraine and I am now 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 range of the weighted 20 total store given by reviewers. Your middle block, for 21 instance, Arkansas and Iowa, ranging from 339 to 341, those 22 then represent the scares of all of the reviewers with the 23 weightings taken into considerat ion, divided by the 24 number of reviewers, and one of those attaches to Arkansas and e-Federal Repottefs, Inc. 25 one attaches to Iowa. 133 Does that answer your question? 2 DR. MAYER: Yeso I guess it does. It causes me 3 some problems. How have you handled those in which someone 4 has failed to put a number down in one of those little 5 blocks? 6 MRS. KYTTLE: Frank. 7 MR. ICHNIOWSKI: 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 MR. ICHNIOWSKI: We counted just as you scored, 13 even with the circles. 14 DR. MAYER: All right, because that has some 15 implications about whether I am going to circle or leave 16 it blank from now on. 17 MR. ICHNIOWSKI: The number of circled items last 18 time comprised only about 15 percent of all the scores, which 19 didn't have a major effect. We tested taking them out and 20 it didn't change it. 21 DR. MAYER: 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 we will start in on the individual 24 projects. It would be my intent to go through them roughly Federal Reporters, Inc. 25 as they are outlined on the sheet. 134 (Whereupon, at 12:50 p.m.t the meeting 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 19 20 21 22 23 24 @e-Fedefal Reporters, Inc. 25 135 I AFTERNOON SESS ION 2 (1:30 p.m.) 3 DR. MAYER: I thought we might before we stawted 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 present,:,,l 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 from Council and as staff then 10 interested it left us the same place we were four months 11 ago when we sent the request up to Council for clarification. 12 We are still on the horns of the same dilemma we had 13 previously. 14 DR. MARGULTES1. -Well, I think that the'best way to 15 handle the kidney review and funding activities is to keep 16 them separate from the Regional hledical Program application 17 itself. I think it is quite clear that this has caused a 18 great amount 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'. 22 We will ask the review committee,with the assistance, oJ 23 outside technical review on each one of the kidney projects, 24 to review the proposal and to make its recommendations I-Fedetat Reporters, Inc. 25 and we will keep that separate from the review of the I Regional Medical Program. This will mean that for each 2 renal project there will be outside consultation -- that is 3 consultation outside of that region, to make sure 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. BESS: Any given renal project will be used 8 specifically for that then. 9 DR. MARGULIES: 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 and 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. MARGIJLIES: Keep the kidney project separate. 19 DR. SCHERLIS: In other words, we make no 20 evaluation of that project. 21 DR. MAYER: Well, I suspect that the evaluation 22 ought to at least include now that Regional Advisory Group 23 and others themselves look upon that and what are that staff'E 24 capabilities of administration. I think those kinds of issues Federal Repoftefs, Inc. 1 25 are probably appropriate. 137 DR. SCHERLIS: As far as funding we look on that 2 entirely separate,, don't make any recommendations on the 3 funding of the renal project? 4 DR. MARGULIES: Not as a part of the site visit 5 or the RMP. The kidney activity would be considered 6 separately. If there is a request for a kidney proposal. at 7 the time that the R14P is being reviewed and 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 Bill has indicated, where 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 enough to have Ed Lewis with 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 program? 20 DR. MARGULIES: Thalts the way we will administer 21 them, yes. 22 DR. SCHERLIS: 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? -Federal Reporters, Inc. 25 DR. MARGULIES: That's pretty much the way it was 138 I 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 RMP activity. And 8 since it has been difficult to,try to look at them in a commoi 9 context I think it is quite clear that we should apply the 10 separate categorical review process. 11 Now 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 way that we do over time cover the nation's needs 15 with centers, so we 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 example, 19 the Greater Delaware Valley -- if you had two hands and two 20 feet on which to count on the site visit at Delaware Valley, 21 it was obvious that they had no plan 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 -Federal Reporters, Inc. 25 way to sit there and say these guys really know what they are 139 I talking about in any category if they are that blind in kidney 2 disease. That's the real problem, and I think 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 has changed -- I mean 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 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, that's 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-ether 17 well enough to do that. 18 DR. IUMGULTES: I think your point is perfectly 19 valid. But one of the things we would anticipate would be 20 looked at in the process of carrying out technical review of 21 a kidney proiposal is whether 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 case then this would not be a e-Fedetal Repoftefs, Inc. 25 fit project for support. I think you will find if you keep them separate in tha 2 review process that it will be possible at the time that 3 the review committee meets to raise the kind of question you 4 just raised more comfortably than if you tired to intertwine 5 them at the time of the review process. We are caught a little 6 bit one way or the other. 7 DR. THURMAN: I would just argue.the reverse. When 8 you are sitting there talking to the guy who is doing all 9 the rest of itt it's very difficult when he says "I cantt 10 count potatoes, but I can count oranges." You wonder how the 11 hell he's doing it. And that'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 way and 14 yet still think of it entirely separately. 15 DR. MAYER: I guess, Bill, where I am, is that I 16 am far more comfortable with a decision having been made, 17 that if those recommendations come from that expert panel 18 and I have been into that region and looked at other ssties 19 and look at what that region is doing about regionalization 20 in other issues, and that review panel on kidney disease comes 21 in, one of the key things that I am going to ask &.9 a review 22 member here is not, you know, the quality of the people 23 involved because supposedly they have looked, but I can ask 24 them about regionalization because I think I know a little -c,,- Federal Reporters, Inc. 25 bit about it. And if it's not there in it then that becomes I issue in my decision. So I think we 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 morning 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 morning would 21 be a good time to do it. It would be an executive session 22 consistin- of the Review Committee and Dr. Margulies and t> 23 whoever else he chooses to bring. 24 All right, are you ready, Leonard, for the great r-redeval Repoitels, Inc. 25 state of Illinois? 142 DR. SCHERLIS: So that's why we are here, isn't it? 2 DR. M@Y-ER: That's one of the reasons. 3 MR. HILTON: Should I, Dr. Mayer, excuse myself? 4 DR. MAYER: I suspect it would probably be appropriate. 5 I 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 DR. SCHERLIS: 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 how much time have you allowed for 14 each review? 15 DR. MAYER: I haven't divided it up. 16 DR. SCHERLIS: About an hour? 17 DR. MAYER: That for review and discussion would 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. Gimbel, and Mr. Ryan. 23 The site visit I think was a very profitable one 24 in the sense that we met the evening before. I think we knew Federa I Repot ters, Inc. 25 what our problems were as far as what some of the difficult I I areas were that we had to explore further. We tried to 2 put most of out emphasis on these areas. 3 you all have,the report. I would like to e mphasize 4 some of the things about it. The report is organized on the 5 basis of our rating system. When we 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. This 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 director, Dr. 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 werf, represented 23 from the entire community, many of whom had traveled a IODG 24 way. And I must say it was one of the better organized and e-Federal Reporters, Inc. 25 most fruitful site visits in terms of having good 144 representation and the information which we 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 ongoing program, determine how this would modify the 9 program 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, which, 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 o 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 -eneral overall 24 e- Federal Reporters, Inc. impression. 25 1 think our overall impression was it was good, and f I 145 1 then we tried to translate that into terms of documentation. 2 First of all, the region has made excellent progress 3 since its last 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 get 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 its responsibilities. It does 14 appear to us that RAG is the decisionmakin- body of the 15 Illinois Regional Medical Program, with a heavy input from the 16 Executive Director, but the final decisionmaking 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 visltci, 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 from 24 minority groups. This is why I made the aside to Mr. Hilton -Federal Reporters, Inc. 25 that I did earlier as far as Illinois was concerned. 146 1 The Executive Director is an extremely knowledgeable 2 individual, knows what is going on with the RMP 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. Creditor, and the Grants 12 Manager, Mrs. Una Creditor, who happens to be his wife, and 13 this is indeed unusual;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 having both people working there, and they both orer, 18 ate, at least 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 patronage. I think it speaks of the act 21 that they happen to be married each to the other. 22 Well, in addition to the Executive Director, 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 f,,- Federal Reporters, Inc. 25 Illinois region, and the participates as the core project 147 I director. I will get involved in this a little more later. 2 Dr. Miller has been involved almost more than anyone 3 else in the country with continuing education for physicians, 4 and his participation as a member 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 may become an 8 issue that RMPS has to consider more and more, the fact 9 that there are such good technical reviews of individual 10 projects, since more and more of these are supported by core 11 there has to be technical review in addition of core, and 12 how this can best be done may be a question of logistics. 13 But this became apparent to us more and more during the 14 period_of our site visit. 15 In Illinois the CHP agencies have been very slow 16 to develop, and Regional Medical Programs contribute markedly 17 particularly toward the development of B agencies, So a lot 18 of the subregionalization of Illinois has been through 19 the vehicle of the B agencies of Comprehensive Health Planning. 20 Now since their new coordinator took over he has, I 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 -Federal Reporters, Inc. 25 reformulated all their goals this summer, and RACT is very 148 I strongly involved with the whole RMP 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 makina existing systems as effective 10 as Possible and catalyzing the development and evaluation 11 of potentially effective alternate systems." 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 IRMP," 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 .e-Federal Reporters, Inc. 25 as I would try to fault motherhood. 149 I They give priorities to all activities best, they. 2 can on'the basis of Al B and C, in that order, and they 3 try to look at these very carefully. 4 One suggestion we made is that the@y, set up-. some sub@- 5 goals on the broad general basis of these three.. Sbi--.we-did-@ 6 suggest that they have some subgoals and@ smaller object@ives@;,. 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 thinkt of good critical review; one on, the- basis--@ thery- had.' 11 not set up adequate evaluation, had na 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 t@he,y- c7an, ar'Tti-eize-- 15 their own programs even though they- WA beerr.. prev,i-du@,y.,- founded 16 imp@mentat As far as specific accomp@hments@ and. -io i. 17 are concerned, they supported projects- Improving cancei-- 18 wh, programs, a coordinated cancer pr ichi has imvoived 19 throughout the region several hospitals., They.- are-- hav@i.ng 20 some problems with this because as other hospitals improve 21 their facilities some of them utilize the, centraL on(y 22 less, but certainly this gives some bo@ as far; as being 23 able to continue them. 24 They have set up a coord@ted home health_ project kce-Federal Repofters, Inc. 25 in northern Cook County, a comprehemsive hea'l:t-h program. They, 150 have multiphasic screening programs in the Chicago area 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,' vtew and, 6 emphasis. But the ones that they have had have been,wail 7 surveyed. They have met with the review', whi-c-h- r. w@ gfy-t. 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- comprehens:L-ve- care-., 12 continuing education for Mid-Southside. And all of these 13 are directed at delivery systems. They havelset up 14 programs which help support ongoin- community healthy and. 15 medical care systems and to help evaluate them@., 16 They are very concerned with, the who-le process: crf-@ 17 evaluation and are looking in their are-& undier- the- 18 continuing education program at the whole concept. of havi:ng 19 a much better method of peer review, and ta this-- they,- arer 20 looking at program oriented charts as their standard. And 21 they regard this as an important decision be-cause they, hope- 22 that by setting up method score evalu@at:Lon.,. utilizing 23 specific problem oriented charts -iii the hospitals- and HMO's,. 24 that this would give them a way of looking at success or failure kce-Federal Reporters, Inc. 25 and patient problems, and they do have the medical societies interested in this as well as their own evaluation groups. 2 The core activities are extremely extensive, and 3 this is wh-y-I mentioned they have used small funds to try, to 4 move in certain specific directions, including support of 5 their educational support resources. This is the@general@ 6 area which is under Dr. George Miller. It has7 been-very 7 effective, and the question we had about thiLs was-. the@ neea-- 8 for technical review from the outside. 9 They have the North Suburban. As@sociation- for Health- 10 Resources, Mid-Southside Health Planning Organization-.. They, 11 have been involved with home planning on a veT-y@ ac-tive basis@-., 12 Study of physician Referral Services, Self-Audit of Family 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 im- pass-ing-- 16 just to summarize it, on RAG 4 of 47, n@in-e perce-nt@ 17 minorities on committees, four percent core, profese-l@ona--i- staff 18 24 percent for secretarial staff, 43 perce.nt. project 19 professional staff -- the way it averages out it c-omes@ 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 proportional 22 minority population in.the state. Twenty- percent that 23 represent'minorities, 13 percent black, & percent Efpan is 24 surname. kce-Fedetal Repoiters, Inc. 25 As I said, Dr. Creditor is a rery, effective-,. dynamic I force-in the Regional Medical Program, has changed it since 2 he took over, and that was 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 prafject, 8 some,very heavy involvement with other objectives. 9 Administratively they have a board of dtr@-o m 10 which has reorganized so that it now has only-fiscal: 11 management,, specifically manages fiscal affaim of the:. 12 corpse ation. We looked into this because we were concerned 13 as to whether or not it became involved with policies. The 14 board does not. It is purely fiscal and, personnel concerned-., 15 It has nine members, six of whom repmse@at thiw schools. of' 16 medicine or osteopathy. Two of them are teach-tng, hospitals.. 17 So all of this is very heavily oriented toward@', the.- medi-cal: 18 school and is purely fiscal-persohnel, and by-every-way we@ 19 could we did establish satisfaction that it iA- pure.L-y-.@ an that 20 basis. 21 1 have alre ady re ad, t he goiLts to, you@.. r won I 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- @ce - Federal Reporters, Inc. 25 members of RAG. So there is a heav-y involvement byLRAG. 153 I These-are the usual-executive, nominating, review, health 2 care delivery, and so on. These are not 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 proposa.L,.eomes- in- :L-t, 9 is easy for the proposer to determine whether or n@ i-t 10 fits into the priorities of IRTIP. B.taff works inf-orma.L.L-y- 11 with them putting together the original application.. rt,- 12 goes to a technical review committee before it goes@ to the 13 overall RAG group. And the review committee is one whi-ch 14 gives out excellent reports. 15 As far as ongoing project survei-L@..L,,anc-a they, haviw 16 adopted a project review which is excellent,. and'. they,, 17 evaluate the projects anywhere from- two, to, four, t@ea, &--@ar, 18 with at least four times a -year looking at it froya,abudget-ary 19 point of view. They carefully go over items,of,t.he:budget, 20 to see whether or not funds are being e@nded'in the direction 21 in which the grant was originally made, and'th-is has:been 22 of help to them in rescuing significant amount-a of funds of- 23 core supported projects. In addition they@ have@ beocn- able, to- 24 maintain a quality of control by these frequent reviews which @ce -Federal Reporters, Inc. 25 appears to be of a high level. 154 We were impressed with the degree of -invol@vement, of 2 local agencies. As we said, the A and B agencies in Illinois 3 leave a great deal to be desired. Dr. Creditor,ut-i-lized the 4 format of the site visit to ask questions of'the Alan& B- 5 agency representatives, which I think will get them off' t@-he-. 6 center in many respects as far as knowing what therir 7 involvement should more strongly be. Thel wors:t artt@iam- 8 was made in terms of their not having developed overall' herait,t.- 9 plans. 10 There appeared to be some schism between- the-- 11 IRMP and the CHP in the regard that I)r. Cred@itor- 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, hitt werer.7 hoping- 16 that the CHP would be more involved both- witit the- planning., 17 and evaluation. They have been of little natty in-. 18 evaluating projects as well. They have of ten- Lef-t- a- great 19 deal to be desired. I think the site visit group@ hese fe.Lt" t, 20 criticisms of the CHP were indeed justifiable. 21 They have been very, I think,, effectiver as-far as 22 their educational programs are coniceraed.. They have 23 established strong relationships not only amongst the medical 24 centers, but certainly amongst the surrounding communities kce-Federal Reporters, Inc. 25 in addition. They have set up what they'referred@ to as- 155 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 HMO'S. And this is not reflected i-n the amount o-t money 5 they have spent, but they have utilized their, staf-E heravily. 6 and small amounts of funds as catalysts in this-regard-. 7 They have functioned as the Iiaison.. amongst- t-h@. 8 35 developing HMO's of the state. So if an@yone: is7 concerned 9 about how many there are in the country r think-- that t-he 10 amount of funds mentioned this morning danllt reall:y,i:ndiiaat,e 11 either the number or the level of support because-so@muc-h- 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 listed. 15 They are anxious as far as developed., adv-anced@ 16 technology in health care, computerized h@.ypertens-@n,servides 17 There was excellent representation from severa.L, of't-hL-- 18 developing HMO's.in this area, and these I th'ink-lare ver.-y 19 heavily involved with the Illinois Re6-ional Medical Program. 20 Some of the specific projects include a radiation 21 therapy treatment plannin- center which helps to@se.,rve 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 ce- Federal Reporters, Inc. 25 they have admitted, have had little influence on discouraging 156 1 sporadic renal trans-plant surgery in other centers, which 2 the three in Chicago appear to be developing quite we-II. 3 They are involved with a comprehensive family orientel 4 community health center to help a povert-y area of s-one 5 10,000, and this is the so-called Valley, projects 6 They are also involved with the Hyde Park--Kenwood- 7 planning for care which will involved some- 45',.GGO@ residents-. 8 I won't continue describing some of the: de-t -@s7 9 except to state that we were impressed that this@was-'a.. 10 region which, given funding, would be able to,,. utJ..Lize-- it I Ieffectively. They have shown the ability as, f ar- as7 L;.eaders-h-ip:- 12 is concerned, as far as having a RAG which reaches 13 responsible decisions, as far as having budgetary controls so 14 that it can cut off programs which are not effective,.as-far as 15 rescuing funds from these projects and utilizin-g.-thex.r 16 think with good judgment. They have good technical'. rev-iiew,not-, 17 only for new projects, but for those@.whicti have, been-. 18 continuing, and not hesitating to cut them off., the problem 19 1 think there is a heavy involvement with 20 of delivery of health care services and with input from, I'thinj,,, 21 many of the projects which are going on in the 'ri-Lina@-s area. 22 I think that given X funds they would be, able, to 23 use these funds quite well. So our concern was not am thei@' 24 ability to utilize funds. ce - Fedeial Repofters, Inc. 25 We felt that we would approve them", and@recommended this number one, we approved their program of-triennial 2 status; number two, that we 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 year they had requested 2.85 million and we recommended 2.6'5';@ 9 for the 04 year they requested 3 million and the f:Lfth-ye@ar 10 3.2 -- I will go over that aga in -- the- t-hir-d',, fourth- and fifth 11 years,they requested 2.84 million for the- thirdi year-. the- 0 12 fourth year 3.0 the fifth year 3.2. Our recommendations for 13 each of those -years in order were 2.65 million, 2@.8 miilioiT, 14 and 3.0 million. 15 We feel this is one of the be@tter- regions- as-- far-@ 16 as being able to utilize these funds, that the.rezis@the- 17 adequate opportunity in the region to do@ th±s-,, anxt the-rerf-dre 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 them. 23 changes of a year ago and the presbn,t @ condition- of@ the@ 24 program. kce - Federal Reporters, Inc. 25 Strong points to me were the codrdinstorl---he is- 158 intelligent, aggressive,, eager, and a good salesman. The 2 RAG is a very good one. It meets frequently. 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 theother- 6 agencies except the Comprehensive Health Planning. The 7 gentleman that was there representin- Comprehensive Health cx 8 Planning was nervous, concerned, really, wasirl't able- to-. 9 propose a very good program, and apparently they havenlt.d-one 10 their part too well. ons ib:L.Lit-y That is not directly, the@res.p t@h-at t,hey- of the RMP, but it does hinder their program 1 2haven't had very good assistance from the CHP,, particularly 13 in planning. 14 There was marked improvement in@ the: gram over,- t-he, 15 pas t ye ar Las t ye ar t he y we re j us t be g-iuxriryg tcp sit, down 16 change their program, change their bylaws,, agree- on@ what. there, 17 might try to do, and they have made, a lot of'progmas, 18 in the last year. 19 They have an excellent method@ of eval:uat:Lcrn@ and@ o 20 developing projects and programs. They have a very good methodc 21 providing funding and shifting those funds to@areas,o:r need,- 22 and reducing funding from programs that are not verylproductive. 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 ice-Fedetat Repottefs, Inc. 25 state, your abilities to meet those needs and proposals to IOU I accomplish these; and they said at that time well, they were 2 just about to do this, and Comprehensive Health Planning 3 was going to. help them 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 r Could 6 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 goiffg, around i.@t,. and@ 9 so we just haven't gotten around to doing this,, that. these, 10 objectives;and programs we have are all good,, the@y'are- 11 national programs, people are bound to need@it,, and'soF-we:are- 12 just going to move right on into this. 13 Well, I'm old-fashioned enough to think i,t might. 14 have been better if they would have looked at-real' needs and.' 15 abilities to accomplish those, and I d@o-al't believed the.-y,@ hav@ 16 done that as well as they might. 17 DR. SCHERLIS: Let me just respGnd tm that, poi-ht,.@ 18 We were concerned -about this, and I think Ycyu: left after- the- 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 -zlet'@ 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-Federal Repofters, Inc. 25 interpretation of data, et cetera." We said-what-da a do i6O you have. He said Ila.LJL the data we have are dirt-y." 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 plo@y- in. 5 e vis it? Who else was on the sit 6 y peculiar ploy, because we- asked them This was a ver 7 for data and they had some of the best analyses of heaLth@, 8 data that we have seen, and when yoo think- about ll:linois and' 9 their Chicago health system, and Dr. Stan and others who colle,.t-- 10 ed down in that area, they hae some very good. data.. I think what they are em@izing 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 am that later- as@ a- mexbe@-- 1, 16 of staff. 17 DR. BRINDLEY: The goals tthat they mentioned': t-cy-. us,, 18 of course. are national goals. TheW are certainly excellent. 19 ones, but they really didn't have vmry good subgoals 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 tbaft the-y are going to 24 develop some regional goals and are now going to get Ace-Federal Reporters, Inc. 25 with this and improve it. But they haven It done as much- as the might.in that regard. 2 Relationships with the CHP still were not as good 3 as they could be. 4 And then I was still concerned some about theL Size 5 of the budget for core. I realize that core is essential,, 6 and it is very important and does lots of things other than 7 administration. But it is about half of the- total budget 8 for the area, and although will 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 noDey. The-y am going- 12 to add three more people for the problem orie@n@ted record,. 13 which we think is probably funded higher than it should' 14 be, and three more physicians are going to larin@ core- tai took@ 15 into this. 16 So I did have those concemm. I dairl't mean to be. 17 unkind. I think they have made great improvement,, and,' :Lt 18 is much better. It did seem to me there are son* axeas 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 reall on a 14 month base., 7 23 which translated back would be aroued a million two,or'so,, 24 what you are essentially recommending is a doubling of' ce-Federat Repotters, Inc. 25 their operational activity. I just wanted to make sure that I- we are all clear orf that. 2 okay, discussion. 3 Yes, John. 4 DR. KRALEWSKI: The question on that core stafl!", 5 I think that is a good one. Do you think they, wi-,.Ll- be abie@ 6 to recruit -- they are going to recruit 22 people, is that- 7 their Ian, to add to that staff? p 8 DR. BRINDIXY: Yes, and they have listed'. the 9 categories they are going to try to fill.. They- dida@'4t say-they 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., ]E"ve: got@ 14 the names down here. They do say they have-those@ needs,, 15 and they related primarily as getting into,the subrp-gional'izatio ,16 effort. We are now going to go out and address- regions and-- 17 have two more schools. 18 Illinois has a ver-y- r@apidl;y, expanding DR. SCHERLIS: 19 medical school system, and they are subregionalizing-.thro@ugh 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 level of 1.5. As they pointed out, this, is probab-ily-the-best- kce-Federat Reporters, Inc. 25 thing that happened to Illinois because they J-ust had to@ I constrict everything'they had. It gave them the opportunity 2 for a total re-evaluation of all the system witbL 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 r. th.ink-in. the 6 Illinois program. They-have some of the best people, r 7 think, around, both as far as evaluation in. the f'ie:LcT of 8 education, and I think the whole problem of evaluating 9 quality of care with HMols 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, proi,orat i-tl 12 is a very ambitious one. There's no question about- it., irut@ 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 that that state vikl have, very.- I am impressed 16 little waste because of their method, of budgetary controls 17 and review and the priority systems they have worke(u 0.11t.., 18 1 would not be as- happy about giving these funds to@man-y- 19 ion can handle, it very other regions. I think this reg 20 effectively and the health needs in Illinois -,you, now, 21 this is a huge state, and you talk about increasing it 22 2.6 million, you think about the size of Illinois an@d-the-y 23 are getting involved now with delivery of heal-th-.systems, 24 this is a very, very expensive area. kce -Federal Reporters, tnc. 25 DR. KRALEWSKI: Do they have any vacancies-on core lfj4 I right.now? 2 DR. SCHERLIS: They have:,a few, but as I pointed 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; s@u-pp@ t(v, a. lot.- of support. And they have been hesitant, for a lot of' reasons,. 7 to hire people knowing they might not get support a:Eter-a- 8 few months. 9 1 am not concerned about their filling them. Tram- 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 IRMP@is.@one-. 14 of organization and is moving-along very effectively.-,. and. 15 not just stars in its eyes, but knows how tautitizw the: 16 health dollar. 17 DR. MAYER: How realistic do 'you t@h-In-k- their- 18 pledge that they took, Dr. Brindle-y, to get outside the 19 city of Ch3Lcago was? That's a big state. 20 they seemed .DR. BRINDLEY: Well, in speaking to us 21 sincere and genuine that they were going to-m-ake a real 22 effort to go to the other areas, and they showed 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 s-chooi'iw A,ce -Federal Reporters, Inc. 25 and area health education centers as it related tothose 165 schools, community-clinics in those areas. Thq,y-dld show somf 2 health plans, home health care plans that would involve 3 other areas out of the Chicago area. They sounded 4 encouraging. 5 -re we -ad@ as,, DR. MAYER: I just wanted to make s@u h 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. We discussed tbLiEr at some- length,--. 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 Number two, more clearly define4 subgoals and.,- 15 objectives; objectives including ones lbr core@ act:t.,vtt-ies- aird-@ 16 educational support resource activity. I referred, to@@ that.. 17 That's Dr. Miller's activity. 18 We also emphasized they had tcx be able to@ 19 evaluate core projects technically. 20 And thre e, increase planning activities directed 21 toward subregionalization of program. 22 The CHP agency was one which r think should work: 23 more effectively, and I think part of their emphasis- an 24 not having data is they want CHP to be more directi@y,i-nvoived @ce-Federal Repoiters, Inc. 25 with planning and helping to get som additional data. You are concerned about the sum of mone-y@we a-re 2 recommending, I gather. I am not. 3 DR. MAYER: Noj I just wanted to point out we were 4 doubling the budget of a region, that's all. 5 DR. BRINDLEY: It is encouraging, E'think-.from 6 the minority viewpoint that tie man in charge of that@ is 7 a member of a minority group. He is one of' the pro-f-'ese:Lon@&i@. 8 members of core. It is his job to go out and re@crui,@,- and 9 to find these people. He is a very energetics enthusiastic' 10 person, and said he was making a real effort to- :rind- these. 11 people both for involvement in the core and also.:Un.,the RAG-,. 12 1 think they are trying their best to get good members. 13 DR. MAYER: Other comments? questions a-f the- two@i 14 reviewers? 15 MISS ANDE.RSON: I was just woader@g- here, o-n- the,- 16 core staff aspect where they are sort of'c:ontradiet-tng- 17 themselves, where they are talking abou-t regional:imati-on,, 18 and extending out to the rest of the state they ask-.fiDr-- 19 three part time staff, a specialist for ITorthwes@tern- .20 University, Western Presbyterian, Chicago Medical, and they 21 are all in 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 something which if they can carry it off it will indeed be kce -Federal Reporters, Inc. 25 excellent experience and that is to get each@ of the- medical 167 schools to take a -p -rtion of Chicago as its area of' 0 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 ay 6 to do it. And part of their attempting ta@do this Involves 7 having support of the schools. 8 we were impressed with the involvment of'the 9 medical schools in their overall community- outreach- programs 10 in Illinois, and the fact that we always had-at, least two 11 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 ttiis@ti-me., II-t-&lked 18 with several of the physicians about it,. and- they@w-e-re 19 more enthusiastic. 20 DR. TMMMAN: 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 thev- can with that. 24 DR. THURMAN: As long as they can breathe, they are @ce - Federal Reporters, Inc. 25 okay. i68 ons? John. DR. MAYFR: Other questi 2 DR. KRALEWSKI: 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. care@. 5 If they are going to add that many people ther are-probably- 6 going to have to phase them in over a period of time,, and 7 if they are going to do that they are probab-ty'n-at going- 8 to be able to spend that core budget, and did -your- 9 cutbacks reflect that that's where your cutbacks-were? 10 So they will probably be able to phase this groupr:Ln@and 11 extend that budget out in that way? 12 DR. SCHERLIS: I really think so, bec--ause@ 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 per@iod-, of time,. 18 is just beginning to turn programs around,. ancT, he has: already 19 fixed in his budget for heavy amounts. If he is going to 20 have any impact it has to be by way of funding and new 21 22 directions, and we put a lot of our faith in his ability to do this on the basis of what he has done by res-cuing small: 23 amounts of money by stopping projects, 'and taking that@m(yne-y 24 they weren't going to use. With RAG and technical review they ce- Federal Reportefs, Inc. 25 have phased out projects on the basis of not measuring up@ to 169 standards, not haviha, adequate review, or not putting funds 2 where they should go. They haven't hesitated to, do@ this. 3 MISS KERR: I got that the f @t time, but did 4 I miss anywhere along the line where yem referred at all to@ 5 their turning over of projects or actirities for outside 6 planning? Are they phasing out any supqport from the outside?-- 7 DR. SCHERLIS: This is a very heavy- criterion. as.@ far- 8 as their review process is concern. Tbas is one of the 9 very strong points. 10 MR. TOOMEY: As they have diw,-xded up the@ city of' 11 Chicago 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 muitlpJLicity of-. 14 DR. SCHERLIS: I should e ize even, if the@y, draw! 15 lines on the map these are real thick, heavy, fu@yl L-tnes@ 16 because some hospitals here work withacommunity hospitals, 17 oat 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 X.R. ..TOONTY: Is the relationship just medical 23 between --'in the hospitals is it the medical school or@ is it 24 relating to administrative as well? ce-Federal Reporters, Inc. 25 DR. SCHERLIS: Their allied health professions are 170 involved very heavily'. They have administratively I 2 can't speak to this. We had specific items that related' to t@het. 3 DR. MAYER: Further comments? 4 MR. NASH: Dr. Scherlis, you seem to be so concerned 5 about the size of core. This includes, of course,. Dr,. Miliertic 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 so= areas of 10 activity that might be funded as projects elsewhere. This is particularly true of their educational resource center' 12 under Dr. George Miller. And so a good part of that core, 13 funding is through Dr. Miller. We suggested that they look 14 at this administratively as well in order to not just let 15 this be an ongoing project through core. one reaso:n;the-y@scrt. 16 it up is because they had it funded three years in.@a;row 17 and it is a continuing resource for.the state,,,, will.itow: 18 become heavily involved with their own problem oriented-t-ype 19 history. 20 But I appreciate that addition. This is one reason. 21 why core is so-- 22 DR. KRAWLEWSKI: Are they going to phase out. t.hat, 23 project or do they plan to stay in it forever? 24 DR. SCHERLIS: I think if you took, the-y@ wi-l:l: bier kce Federal Reporters, Inc. 25 in it a while longer. We did as one of our suggestions 17i I emphasize they look-at that whole administrative structure 2 and set up some ongoing technical review of it periodically. 3 So this wonI.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,s:upported by 6 RMP. It should- be added that this is not a major part of 7 the support by any means. He has a great deal- of e-up ,port. 8 ongoing. I guess from the whole manpower and ather,agencles. 9 DR. PERRY: The Keilogg Foundation hW@ jus-t 10 funded a half million dollar project. 'DR. SCHERLIS-. y@ 11 This isn*t something he.- needs oni 12 for this. These funds are specifically related@ to RMP, 13 activities. 14 DR. MAYER: Other comments? 15 Then -your recommendation is twcr 6-50@ 16 two million eight, three million respectively-.. 17 DR. SCHERLIS: Yes, I make that in@the fdrm,@oE a. 18 motion. 19 DR-. BRINDLEY: Second. 20 DR. MAYER: Discussion? 21 Al I those in f avor? 22 (Chorus of "ayes.',) 23 'Opposed? 24 (No response.) ce-Federal Reporters, Inc. 25 Well, let's take a minute to fill in the blanks I 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 airead-y- a 6 matter of record, andI don't want to be caught in any- 7 inconsistencies. DR. MAYER: Can it be recaptured?' 8 9 W. NASH: I have one from Dr. Scherlis. 1. dOM@l't 10 believe I got one from Dr. Brindley. 11 DR. MAYER: Leonard it sounds like y-ow are 12 excused and Dr. Brindley is not. 13 DR. SCHERLIS: I am safe. He has mine@.. 14 DR. MAYER: I think We might move air then,,. Sister- 15 ADD, to Maryland. 16 SISTER ANN JOSEPHINE: All right.. The, M@land@ 17 site visit-- 18 DR. MAYER: The record will show that Dr@., Scheriis 19 has left the room. 20 SISTER ANN JOSEPHINE- The Maryland site visit was 21 made on December 8 and 9, and members of the site visit 22 team were Dr. Alexander Mcphedran, Emory University Cl-ini@,, 23 and Dr. William McBeath, who is the Director of the Ohio 24 t the site- Valley Regional Medical Program. Staff present a Ace-Federal Reporters, Inc. 25 visit were Dr. John Farrell of the Health Maintenance 173 I organizations Division-- we were very happy to -have him with 2 us because a substantial portion of the grant request from 3 Maryland is.for health maintenance organization related 4 projects -- Mr. Harold OtFlaherty, from the planning and 5 Evaluation Division, who prepared a very- pr-ovar-at,iv4w @t of 6 questions that we used the first evening pr-lor,to the site 7 visit to kind of get on the same wave Len gth- so@: that- wer 8 could evaluate the type of inquiry that we were going-to conduct 9 as the site visit progressed; Mr. Clyde Ciauc.hman-,. thcr 10 regional office representativ e from Regiort III,-;, anft Mr. @orge I I Hinkle from the Eastern Operations Brancly.. An;f., we. - ha& 12 requested Mr. Hinkle to prepare a document that.indi-eated the 13 questions that the previous site visitors had ha&.,. and then 14 to also indicate what corrections had, been, made. so-- that@ this 15 would also serve as the basis of' discussions.. 16 Following the discussion evening prior- to-, the. meetino,,., 17 we decided that it might be of advantage if the-ah@-man 18 of the site visit-team were to meetvith the Goo@rdi:nator, 19 of the program at breakfast so tbLat Imss-ibl'y a good rapport 20 could be established between the site visit chairman and t 21 coordinator which would facilitate the site visit.. And I- 22 think that we had not done this an previous site visits I' 23 have attended, and I personally found this very-heipf'ui. 24 The Maryland Regional Medical Program wi'i'l@have kce-Fedetal Repoiters, Inc. 25 completed its first three years as an operational@.program on 174 I February 29, 1972. 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 eve-n-ing.. 9 before the site visit began was that the Mar-ytand'. Regional., 10 Medical Program has responded to the directives from thec. national program in such a way that the program represents 12 almost a 180 degree shift in goals and priorities and 13 emphais. And it should also be noted that this. is,a@program 14 that has experienced a high turnover rate@ in, coor&inators,.. 15 In the five years of the program the@re, have been- :rivo@ t 16 coordinators. 17 Dr. Davens, the present coordinatox,,, has- had- some, 18 involvement and has been interested in,HMG's,, whiah:i@ also 19 reflected in the proposals that have been made-. 20 Johns Hopkins University is the grantee organization 21 for the Regional Medical Program. And in the state are.- the 22 two medical schools, Johns Hopkins and the TJhlvers-i-,t-y of-- 23 Maryland. 24 On the prior site visit the site visitors were kce -Federal Reporters, Inc. 25 disturbed by the fact that it appeared that the@Regional 175 Medical Program was-heavily dominated by the two medical 2 schools. 3 The site visitors found that the Mary-land 4 Regional Advisory Group has been expanded from 27,to-35 members, 5 and this in response to a criticism on the last site vi-s-kt@, 6 and the total committee structure has been changed. Five@ 7 of the twelve committees which have been'establishea 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 bealt-h education steeri-ng- 13 committees. Two are structured to relate to the core staff' 14 administrative organization; and one,., the Western, Maryland' 15 Regional Advisory Group, has been recently established t.a,, 16 provide greater peripheral representation. omn-xttees have- a, wr-ittem 17 In each instance the c 18 charge developed.in part bv 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 s sup@ed by a staff consisting 23 of 18 professionals and 14 secret@al-c.Lerical personnel', 24 of which five positions are part t me. Nce-Federal Reporters, Inc. 25 The core staff organizationally consists of the 176 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 Real-th Manpower@ 8 Development and Continuing Communication Division-. 9 Organizational changes have bee-a, made in@ an att@empt- 10 to provide a broader base for management and: al'sm to-. try,- t'O 11 eliminate the domination of the two, medical schools2 ih- the- 12 area. 13 The Epidemiology and Statistics Center-,, whiah: is@ 14 associated with Johns Hopkins MedicaJL Center@,, has:- beren, more 15 closely tied to the central core mait, and, :Ls@ now- funatil"ibT-1 16 as the principal health intelligence- and; evaluation- arm. 17 of the Maryland Regional Medical, P Pre-v.:Laual:@y, the-r.@- 18 was some concern that this cente-r was ftLnded, as--, a: u-nit@ within: 19 the core structure, however it was functioning.ind -@ndent, 20 of it. 21 in the guidelines that were developed and. published, in 22 August of 1971 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- w o- 6ce-Fede[al Repofters, Inc. 25 were presenting the programs at some points it wasn't, too clear exactly how the E and S Center has been providing an- 2 ongoing evaluati on service. 3 In. response to change in direction. expressed in 4 the RMPS new mission statements, Dr. DeLvens reported that- 5 the medical school involvement in Regiamat Medica.L Program 6 activities has been redirected from continuing education 7 to planning and development of he,altbL @ittenance organizations 8 and training of health professionals and.. new- ty .pew o-t healt@h 9 personnel. I 0 The director of the Epiodemology- and. S:tat-isti-c-a 11 Center,, Dr. Leon Gordis, is moving to@ 4tireet the, e@ft: of@ his 12 staff toward the new mission of Region@eLl Medical program, 13 especially in the areas of collection. and@ anal@ys7is- @ data 14 with specif ic reference to defined areas. where them- :Usr- interest 15 in and heed for the development of a @a.Uth,., ma:Lnte.naiiee- 16 organization and area health education centers,.. 17 Dr. Davrens reported that sincer the, East., sit-e- 18 visit one of the crigicisms that was xLade; was that-, there- 19 was no evidence of cooperative efforts with Comprehensive 20 Health Planning, and this could be d=umented at the 21 present time. 22 There is increased minority group representation-. 23 There has been a discontinl2eLnce of the@ 'University of 24 Maryland tissue typing project, and Dr. Davrens repeatedly 'e-Fedetal Reporters, Inc. 25 reassured the site visitors that -although the medical' @hools@ 178 I support the Regional Medical Program they do not interfere 2 or attempt to control the pr @ am. 3 In. view of the recent changing emphasis in the 4 strategy of Regional Medical Programm,. the 9-i-.tel visit- team 5 elected to evaluate the Maryland Region-at Medical P@am 6 goals, objectives and priorities with respec-t to- thw- proposed- new as well as past activity. 7 8 The goals, objectives and @orities are aibarly. 9 and explicitly stated, and the site visit team-was: 10 impressed with the fact that the objectives pTopcs-e--d-. for 11 the triennial period clearly reflect the; ob-,tectives,. goals 12 and priorities that are stated in their application. 13 DR. MAYER: Excuse me, Sister,. did: you@ say., are 14 explicitly stated or inexplicitly? 15 SISTER ANN JOS@rn: thely- arqr exptici-tLy,, 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 rerwri-te- to%me. 19 SISTER ANN JOSEPHINE: That"s right., That.lir 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 onhe-alth maintenance 23 organizations, area health education centers-,. again- was:- 24 stated in such a way that it was a direct. restatement- of-' the@ ,ce-Fedefal Reportets, Inc. 25 directives from the national program.. 179 I 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 prev-ious -years seemed 5 to be dropped without any planning or any phas-ing 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, objective, 8 rather than following careful evaluation and ini response-- 9 to the needs in the Tea. 10 The two projects for Mlo'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 were- 14 submitted under new projects. 15 The RAG -- although the mm-be,rshi,g of RAG7, has- beery- 16 increased, the site visitors were dia-tu@rbed that ther 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 program. He appears to be relating. well tat the 23 representatives from the two medical schools,. ancT he appears to) 24 be communicating with RAG. However, as we had an opportunity kce - Federal Reporters, Inc. 25 to discuss the activities of RAG with the members who were 180 I invited to the meeting, it was our impression that RAG took 2 their direction from the coordinator, and although they were 3 informationof day to day operations, that possibly RAG 4 was not as strong as it needed to be in order to fu:ifill its 5 role. Also RAG meets once a month, and does not have an. 6 executive committee; and in discussing the reasons why 7 they chose to go this way in their organization it became 8 apparent that because most of the representatives are from Baltimore that it is easy for them to meet this way, and 10 because there doesn't seem to be a veil developed program they 11 have not really experienced A need for an executive committee. 12 Approximately two-thirds of the core staff are full 13 time, and there are only three vacancies, and Dr. Davre-ns 14 assured us that these three vacancies could be filled'.. 15 Many of the concerns raised about the care staff in. 16 the past were predicated u n the fact that essentiati.y- they. PO 17 were part time, and Dr. Davrens has gone a long way in@ 18 terms of changing 'this situation. 19 The site visitors are sti.Li unclear as towhet-her 20 in reality Dr. Davrens and his support staff are providing 21 leadership to the medical schools in terms of the Regional 22 Medical Program mission or if the medical-schoois are 23 dictating the direction to the Maryland Regional Medical 24 Program. kce- Federal Reporters, Inc. 25 The grantee organization, as I mentioned before, I is Johns Hopkins University School of Medicine, -and it 2 appears to have a very positive relationship with the Maryland 3 Regional Medical Program 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. ANCRUIA: As far as participations in-: the seem tol@ have-. cfui--te- 8 Maryland Regional Medical Program, the.-y do 9 a variety of organizations and other professions in.-the 10 Baltimore area especially participating in that program.. 11 They had some of the visitors there from some of the proje-ats 12 that were going on, also other interested citizens around 13 the,Baltimore area. Also they were vvry helpful. in hei.ping- 14 to get the Maryland Health Maintenancel Committee @arted-,, 15 which is a group that is currently operating-- 16 DR. MAYER: Gladys, is that one wired down- therre for sound? You were coming throu unt:UL. 17 gh fine, Glad-ys 18 we got the additional noise. 19 DR. ANCRUld: They did play an active role i-n@ 20 helping tD establish the Maryland'HealLth Maintenance Committee, 21 which is currently operating a health center in. one of' the- 22 underprivileged areas in Baltimore. The,y do utilize some 23 of the community practitioners and "so othe-r@ community' aides 24 for operating this facility. kce- Federal Reporters, Inc. 25 Also Sister said earlier @t of the planning- for- 182 the area has been locally and throughout the Baltimore area. 2 The one way they seem to be moving away from 3 Baltimore is through the Manpower Development and Continuing. 4 Communication under Dr. Herbert's leadership. 5 Also they do have plans for correcting some. of 6 this and becoming more active in subregionalization by 7 involving the comprehensive health planning B agency. 8 There was a question among the site visitors about 9 how they were using the assessment of regional resources. 10 The Epidemiological and Statistical Center did collect a- 11 large amount of data, but we weren't able to determine as to. 12 how did they utilize this data in determining beeds, and. also 13 using this as a baseline for developing some of their 14 programs. 15 In the management they seem@to be emphas@iz-ing- :te@ 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 healtbL 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 He alth Manpower and Continuing 23 Communication, and which they referred back to community 24 activities that went on with their second Monday series- Lce- Federal Reporters, Inc. 25 several times throughout their presentation. 183 Also the-w&y 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 t@- toodk, 8 ing at the project for ongoing evaluation they also h-ave;&. 9 committee that reviews the proposals and helps with- being@ 10 sure that they do have quantitative that c,an@ 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, However,, we we-rel not- 16 clear as to how much direction for the center came from 17 Dr. Davens or they were still operating more orle:ss- as a', 18 separate entity. 19 They have also worked out a conceptual strategy 20 for evaluating all the programs, and they do have five 21 steps that they follow. These are determine the project 22 goals, determine the project objectives, determine the 23 measurement of objectives attained, and also establish 24 standar@ and collection of the data on performance, and: @ce- Federal Reporteis, Inc. 25 comparison of actual performance with standards previously set 184 Also there -was a request for budget for the 2 Epidemiological and Statistical Center in which they asked for 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'ther 6 budget outline. 7 The program proposals that the rogram@ have-,, as@ p 8 Sister pointed out, they do seem to be leaning quite 9 heavily on the national goals that were sent ou. ixy the@ new 10 mission statement. 11 In view of the major thrust in the, new, are.@as-- o-L 12 the health maintenance organization it is believe that the 13 proposed efforts would strengthen the service in the 14 underprivileged areas. I did mention about the one po:Ln..t that the-,y.@ hav 15 16 going with the health maintenance organization., They@ a@o- 17 had another in Columbia, I believe it is, the. Toh-ns- Hopkins 18 school. 19 Under the area of continuing education-,. he-r@ is: wherr3p 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. ce-Federal Repoiters, Inc. 25 Also they have a home care program which is 185 designed to give comprehensive home care to families. And 2 also with the school of nursing at the University of 3 Ilaryland they are currently starting preparation for-f-amily 4 nurse practitions. The site visit team felt th @ the- activities that 5 6 the program had projected for the comimg year, we-re realistic. 7 However., one thing that they felt coal4 have been-. improved, 8 was that the medical schools could hwe made- a Substantial. 9 contribution to areas other than just :in. the- HtEaLth, 10 Maintenance organization. 11 'In dissemination of knowleftm- we we-reE assured- that 12 wider groups and institutions would eive immediate 13 benefits from the activities that planned' and also- 14 those ongoing. However, it was diff i,@t- to@ p@poi-nt- what- 15 available benefit the informations would provid@- grolulm-- in-. thie,- 16 outer area. 17 One of the other projects, too@,, is- ttie-y,- 18 starting an information center in which the Re.giO@nai'M6dical@ 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 will be getting information from insurance comp&n es. 22 and others about people who come in for-the treatment 23 of drugs.- 24 Do -you want to add anything? ce-Federal Reporters, Inc. 25 SISTER ANN JOSEPHINE: The questions that weren't 186 1 answered to the site visitors' satisfaction. really were the 2 following: 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- werel a. response-, 5 to the new direction from the. Regional Me-dicaL.Program. 6 Also there was some concern that most of the proposed 7 activities to be carried out over thel next thr@, yo@-@ will@ 8 be geographically located in Battimore,@ and that raughtly- 9 25 percent of the requested budget is going7for-HMG-,,activiities, 10 and it was unclear again on what basis this decision I I was made other than again in@ response to, legi-s-ilatioir and-' 12 existing activity that had been going on,.. 13 We were unsure about the nature of the,. rerg-ion's. 14 planning process and at what point i-n! the- d"Erlopment- of-' 15 a project evaluation is built la- 16 Also we were not clear about. the. nature-- o:f' the@ 17 strategy and methodology used. for, carrying aiLt-, proj-,igct 18 evaluation, nor was it entirely-clear@whoocarr.ies-out project 19 evaluation, project staff or center-staff., T-herre: was 20 indication that this is presently being worked out, but-t-hat 21 in many instances it was not applied to the projects in the@ 22 proposal that were submitted for triennial support,.. Also. 23 we were not clear as to how the results of evaluation 24 activities affect the regionts decisionmaking process. ce- Federal Reporters, Inc. 25 And for those reasons we thought it wise o 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 $lr294s960. And 4 originally the proposal was to approve it at a. level of 5 $1,325,000, but in the recent mail a commurlicat@ion@came from 6 Washington stating that the recommendations of the 7 Mini-Sarp review on the anti-lymphocyte globulin for@ ran&J- 8 Allograph project number 43 be deferred pending national 9 RMP policy on funding ALry production. 10 We are recommending that the developmental componernt- 11 not be supported, and we are recommending that the.-project 12 level of $861,,313 be reduced to $714,0,04. And the areas 13 in which we are making reduction are in the@ areas,of the 14 Health Maintenance Organization proposal submitted by- the 15 University of Maryland Medical Sch@ contract for- $&7,2'30'W., 16 Dr. Farrell -- is Dr. Farrell here? Dr@., Parrel@L 17 was present on the site visit team, mO it was his 18 recommendation, and the group concurred, that since the other 19 organization that is supporting KMO activities will provide 20 $25,000 for a feasi bilit@y 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 @opriate.. 24 Also it was the decision of the site visit team @ce-Fedefat Reporters, Inc. 25 that mini-contracts which had been used by this Regional' 188 I Medical Program and-were funded at a level of $95t 270 be 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'realiy-- 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 14ed@icat Program,, I I but it was also pointed out that many peop,ie- wou@ld'be: 12 attracted to any program that had money to give'out.. S-@,that 13 possibly this might become a slush fund unless. it were 14 controlled in a different way. 15 on page 19 of the Maryland Regiona,!, Med'i,,aaL, 16 Program site visit that is included in your folder@are the 17 site visit team recommendations, and membe-rs. of the staffa;nd 18 Dr. Ancrum and I would be glad to answer any (Luest-ions 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 ce -Federal Repof ters, 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 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. MAYER: This in effect then is a reduction 8 of almost 300,000,$280,000 over their c nt operating 9 level. The interesting thing to me was it still provides 10 them with about -- if I am reading the yeliow-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 I[ am 14 reading those yellow sheets correctly. is that carraLct? Are 15 they phasing that much out? 16 On one hand it says that the activity, thi-A- year,, 17 is at a million 672 in the 03 year, and then an the other- is hand it shows for the 04 program continuation with-approved 19 period of support, and continuation beyond shows: only 20 741,000, which suggests to me that the@y phased out about 21 $600,000 somewhere. 22 DR. ANCRUM: I think they phased it out during 23 the time there was a reduction in the funds, they-had a 24 25 percent cut and they phased out saw of the program. They @ce- Federal Reporters, Inc. 25 used the amount that was in the ongofmg program. 190 DR. MAYER: I guess the point is that they have got 2 a million six now in operation, and 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 abou-t@' 7 eight or nine projects that come into the end of the- 03-' 8 year support period. The sheet you are took.ing-et,. the- 9 only activity they have ongoing in their request iw number 10 19 and number 27 and project number 35 which are in-,this summary which all of you have a copy of. An-ythi-ng-else:, ai'J-' 12 their work in the area of stroke, coronary care units,-exe, 13 all coming to an end. That's what Sister Antr. referred to 1 4 a minute ago when she said they had done a lgad-egre-e,tu.rn- 15 around in the program. 16 DR. MAYER: So that on the one- hand, a-Ithough@ it.-Iq- 17 a reduction of current operating activity- ft"s an@. increaser, 18 in terms of dollars togo into new program. Th-at"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-I underrstand 23 the relationship between the proposed m-ini-contracts where 24 they request $95 000 and how they expect to use this money ,ce - Federal Reporters, Inc. 25 other than their developmental component. As I read the 191 t to be able to respond I application I gather that they wan 2 quickly to changes in RMP mission and evolving new thrusts 3 in national,health programs,, and this is really a description 4 of what the development component is. And yet you.suggest that the developmental component not be funded, but that 5 6 the mini-contract be funded in part. 7 SISTER ANN JOSEPHINE: WeliL, I agree witb, -you- on 8 that. The mini-contracts as we heard them described and 9 we asked several times -- were described in such a way-t.hat 10 they could be describing the developmental component rt. 11 was the thinking of the group that rat-her 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- relate@s- 16 to the $25,000 that is recommended for project number 37,. ad this. University 17 the HMO health care study. Again as I re 18 of Maryland HMO proposal I wonder @ther the admonition 19 that Dr. Margulies mentioned this morning about M%Srole i@n- 20 HMO's being eliminated to follow the assessment of 21 manpower utilization and emergency medical services, whether 22 what they propose to do with this HM health care study doe-snt 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-Federal ReporteFS, Inc. 25 clearly lie beyond the purview of R.VPS purposes, and so I 192 I am wondering why even this 250000 is-- 2 SISTER ANN JOSEPHINE: Dr. Besson, there were 3 members of the site visit team who raised the same qgestion@, 4 you are raising, and at that point we turned to Dr-.,Farrell. 5 who was there representing the HMO operation, and- askeid@ him 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 Program support. And I k-now-at the.,t-ime@ 10 this discussion went on there were those who.r@aised t-he@ 11 question whether at a future date, since we d-o!not. have an-y-- 12 guidelines that enable us to make 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 re-a.L'. 15 problems since the HMO effort is being funded:from:two, 16 separate pots' and say., you know, how much of the RIIP'mone@y- 17 should go into this. This question was raisiad',, and-. 18 probably someone else from staff wants ta comment. (Yn@ this-.. 19 I would also share your concern.. 20 MR. TOOMEY: Sister, I am confused, because on 21 page 21 of the -3ellow sheets you have got the HMO information 22 system which is with Johns Hopkins, end then- you have-a 23 contract with the HMO health care system at the Uhi-versit@y of' 24 Maryland, and I understood you to say that the one at @ce-Federat Reporters, Inc. 25 the University of Maryland you disallowed. 193 SISTER ANN JOSEPHINE: This would be reduced from 2 172 thousand to 25. 3 TOO-MEY: How about the one at Johns Hopkins? 4 SISTER ANN JOSEPHINE: Well, the one at Tohns- 5 Hopkins -- and again we relied on Dr. Parre@ll as-wewere 6 making this decision -- the one at Johns Hopkins was-allowed 7 for the amount that they requested. Appexen:tiy,the, 8 center at Johns Hopkins University is aLLready, participating, 9 or providing data for the national effcsrt in evaluating 10 Health Maintenance Organizations-- MR. TOOMEY: Is that the East Baltimore- 12 SISTER ANN JOBF.PHI.NE: I thinks Dr. FarreLJL felt 13 that if this were disallowed that it afLght interfere with 14 this other ef fort', and I think- this ifto-le- thing Llin@ glad-- 15 this came up because I think this where HMO dis-c@us-s@n-. nerercm. 16 whatever clarification can possibly be given here from sta;f@,f... 17 MR. TOONEEY: And then you 'bave anothe@ 18 of Maryland . the Bon Secours Comprehensive Health- C-einter 19 is involved with the home care program. 20 SISTER A NN JOSEPHINE: Yes, and that home care 21 program is under this health educati@m. 22 MR. TOOMEY: It just would seem to me that what they 23 were doing is trying in a way to spl:it the derivation o:U 24 information between the single efforts of the@two, ce- Federal Reporters, Inc. 25 universities to provide health services through these HMO'@. 194 SISTER ANN JOSEPHINE: Yes., we shared_your concern. 2 MR. TOOMEY: Actually one of them could probably 3 have taken the 'whole ball of wax. 4 DR. THIURMAN: Could we cax" that just. one step 5 further because on the top of 23@ there is. an@er-- $84", 000 6 for HMO's which looks like it's really the EkS'cente-r. 7 The two on 21 that Dr. Toomey has referred'to-andan-.ther.- 8 top of 23 is another $84,000 for HMO'-s, 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@ oE tbesir contracts-,, 11 and the fourth one. too, would. go. back,, to, Ek.5ji which@ is--@ going@'. 12 to make it a pretty expensive- operations.. 13 MR. TOOMEY: May I ask is this@Mar'land,.H#ait@h y Maintenance Committee incorporated?- Is@ that.- t,.he- Cdiumbi@ 14 15 Maryland-- SISTER ANN JOSEPHINE-. ITo:.. No,., 17 Y: WeLl. did youi me@n-t.,:Lort th@- the-y,we,re,- MR. TOOME 18 involved in that?- 19 SISTER ANN JOSEPHINE.- No,,, I (fidn"t., This 20 corporation is one that Dr. Daven has been working with and- 21 has been interested in. 22 DR. THURMAN: They also have another,contract,.from 23 another-- 24 SISTER ANN JOSEPHINE:- That"s right. The- whole- ,ce- Federal Reporters, Inc. 25 HMO area here is very muddy, and this was the reason I@think 195 I Dr. Farrell was provided from staff. This never was really 2 made clear,, and then today after Dr. Margulies' remarks 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 HMO concepts the question I would raise tehow much 7 money should be supplied from Regional @tedicaL Pr@ams., But'. 8 if I heard the discussion this morning I think@t@hat this is 9 not a part of the consideration. Is that right?@ Whic.h.is 10 a little confusing to me. MR. CHILMBLISS- I would think so,,. ilf I[, mi-ght@.- just, 12 answer a bit here. It is my understanding that- the: li-mite@d@ 13 amount, not to eXceed $25,000, might be used@ifor@plannkng- 14 and development for the feasibility aspects@ o-f@ the-HMOot 15 that the larger amounts have to do direc-ti3r wi-.th@ the:- 16 actuarial side, the marketing,, the packaging,, tha:e-stab.Lishmert. 17 of an HMO and the funding of it, the front funds re-qplre-d@@ 18 to get it going. - And that is not with:Ln. the province-. of-' 19 RMPS. But certainly as it relates to planning.-of the 20 initial feasibility and the monitoring of the quality of 21 service rendered therein those are two aspects which 22 Regional Medical Pr6gramg could be involved with kts-fltnds. 23 'DR. MAYER: Would -you like to comment? 24 MR. HINEM: Yes, Dr. Thurman made reference to ,ce - Federal Reporters, Inc. 25 the EMS. They are supported by total budget of 179 or 189 thousand dollars. Now with reference to the HMO part of@ 2 $84,,700, that is in conjunction with a contract the HMO 3 office has made with Maryland Health Maintenance Committee 4 in Ma2yland, and the RMP of Maryland decided they 5 obligated themselves to take on the responsibility o-f setting 6 up an evaluation mechanism for this Maryland'HiBalth 7 Maintenance Organization committee up% there:,, an(! that. is,- 8 to set up an HMO other than the one the-y-have ongoing-now.. 9 They have one through Johns Hopkins and' this atherlone. And@ 10 they are going to try to set up-an evaluation-mechanism fDr@- 11 this Maryland Health Maintenance Comit-tee@ HMO-@ activity,,, 12 which is adkmrted about $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 M-arylieLad. 15 And repeatedly -- and i[ think i-t was Mentioned 16 before here -- we asked the same question,,,, why can-;It. the 17 EMS center set up this mechanisuL, and. they- ropeaterdl)r- 18 advised us that they are overworked now,,, they@ d-on@lt,. have 19 sufficient staff to take on this additional responsibility.. 20 reason they have a separate project So that's the 21 in here to go out and get outside assistance i-n-t a 22 evaluation. 23 DR. THURMAN: It says will also be part o-f-'t-he@ new 24 activity of the M center core staff. So thatlis not %ce Fedetal Repofters, Inc. 25 outside. 197 MR, HINKLE-- I was speaking about the $54,700-. 2 DR. THURMAN: So was I. The last statement under 3 the 84,000 one is "will also be part of the activity o:t the 4 E&B center core staff." 5 MR. HINKLX: But this 84,,OOG is, to, @@ outside and 6 got theessistanc,e to set it up,, and the E&S center has their 7 hand in everything going on up there, and they@ ar.@ also-- going- 8 to help in there. But they dont pinpoint how-much of-their 9 $187,000 will supplement the 84,700. lo DR. MAYER: Welig what that said to.-@ me-,, Bk.UJL,, was 11 the EIIS center was going to carry out an evatuat-ilon-. of- that. 12 contracted outside evaluation system. ITow is. that@ what. they. 13 are planning on doing? 14 MR. HINKIZO. No-- 15 DR. MAYER: They are going to do) :L@t7l 16 MR. HINKLE- They are going to, assis-t In it,..@ They 17 are going outside to get help to do it becaus-L-. their 18 staff, their overworked status up there which.they@kept- 19 referring to, it doesn It have enough people to. do it@ oil 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 MR. HINKLE: In reading the project anythi-ng that 24 has to do with the mission they say EM center is goi@ng to have kce-Federat Repotters, Inc. 25 a hand in it also. There is a surve7 which they axe going to conduct with outside funds, which is another project, 2 and we asked them why can't the E&S center conduct this. 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 JOSEPHI-NE: I got the impressiong.too, 7 that the E&S center is already -- Someone has. contracted 8 with the E&S center to provide some of this data, correction 9 and evaluation, and are presently engaged in it., l'O MR. HINKLE: This point is anothe-v aspect that the@- 11 site visit kept focusing on,, the site w:Ls:i,,tora wanti-ng@ to- know 12 why the E&-S center is doing so much outside evaluation- work. 13 for other people, why can't they get these people ta.pay for 14 it. And they f ioal ly in the f ina-L analysis- said they,- haver 15 been thinking along those lines and the@5F plane, tolt have.- 16 the E&-S center contract outside. 17 Now on one hand they say their.- a-taff7 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- jtst- 20 one of the ambiguit ies we kept running into every time we would 21 ask questions. 22 DR. ldAYER: 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-' kce -Federal Reporters, Inc. 25 clarity of that, and we wondered if you, could comment about it. I DR. FARRELL: Yes. This is the University of 2 Maryland? 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 7 what 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 HMO service are to the 10 extent of $25,000 limit, and this was three -years for-something 11 in the range of $187,000 a year, if I remenbe@rtt.. 12 DR. THURMAN: Why was there a d@ifference@@between the 13 Tiniversity 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 lity,- care. operational HMO, and they are doing a specific q@a 17 project. 18 DR. KRAWLEWSKI: Were you able to.@ determine how 19 many other granting agencies were involved in these HMO activities 20 in these schools and whether 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. KRAWLEWSKI: Do they have a grant from an kce Federal Reporters, Inc. 25 insurance company also? e Columbia project yoti mean? DR. FARRELL: Th 2 DR.,KRAWLEWSKI: Right. 3 MR, TOOMEY: Nov the East Baltimore project. The 4 East Baltimore project has somewhere'in the-ne-ighborhood of 5 15 to 20 federal programs Participating in that... I'. don't 6 know whether you call it an HRO at the moment,,but in actual 7 practice-- 8 DR. KRAWLEIWSKI: And the national center has some 9 money in that in an evaluation form? 10 DR. FARRELL: There are all the spec-if,:Le- aspects, an@ , 11 of course it is one of these arganizat.ioner- that'lis- being- ii 12 looked at from about twelve different angles., rti:s not 13 typical. 14 real l-y DR. BESSON: ?Ar. Chairman.,, E think: we- ar4w, 15 talking about something that we will hear,many,-moye.,times 16 before we see the end of EENOS, and it wish,. be7 wei.,JL'- for us 17 to make sure that we have a clear statement :Ur-om@ t-@- Council 18 and suggest what R.@IP's bag is going to be@in HMO. l@.heard 19 Mr. Chambliss say that one of the reasons we are funding 20 his 25,000 is to project 36 perhaps or why we are giving t 21 study feasibility, and as I read at least our local,guruls 22 interpretation of what HMO's relationship to-@RMP'shou.id be 23 it's not for feasibility. That should ber ther@ HMO-, organization 24 in HSHMA. kce-Federat Reporters, Inc. 25 -1 think that this being the bottomless pit that it 201 I is, feasibility studies, developmental studiesp-et ceterap 2 requested from RMP 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 goin@ to-be7ftinded 6 and another is not. The entire project summary appears :Ln 7 no greater detail than this yellow sheet does except-by a slight 8 amount. And therefore we are left with just a series-of' 9 cliches, some of which are okay words,, and s-ome:of which are 10 not. 11 But as I look at project number@36 which@we are 12 suggesting may be funded, I see some okaywords like routine 13 monitoring of the volume and types of medical services,.but 14 I see some non-okay words IiJke'providlng all necessary 15 financial billing functions and summary, revenue statements- 16 for accounting purposes data for mee-ttng the reporting 17 requirements of various external administrative, agernc _ies 18 actuarial useful data for estimating future utilization of co- 19 payment revenues and capitation costs. These are clearly .20 not within RMPS purview. 21 So I am not sure whether the-re isn't a little bit o 22 misemphasis in using some words that will again push the 23 bitton that gets the green pellet. And we went through this wih 24 cardiopulmonary rescussitation a few years ago and'ca-rdiac kce- Federal Reporters, Inc. 25 care unit, and if they said those magic words, bang went the 202 dollars. And am-a-little bit afraid that this is what we 2 are beginning to see with IMO'S. So maybe at this early -t statement 3 stage of the game we should get a very explici 4 from Council as to just what RMP's bag is in relation to 5 HMO'S. And I would so move, couched in more, elegant language. 6 DR. MAYER: All right. 7 DR. BESSON: We have a motion an the- f.-Loo-r-,. 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 :Lntent 11 I gather the intent -- let me try to sumnarize,what r@pick- 12 up now from what has been said. That. what you@ were@ saying_, 13 Sister,, was a deletion of the project, componen't- by, about 14 $150,000, the basis of which was re&Hy- de@tat@ion- of' that from 15 project 37, the University of Marylmd EINO', with-. the, 16 provision of about $25,000 in that project for- the eff-byt- 17 as it relates to the planning for HMO aC@tiVit'y--., 7 that. 18 correct? 19 SISTER ANN JOSEPHINE: Yes- 20 -DR. MAYER And secondly ym therefore were saying 21 full funding of project 36. And Jeery Just raised- them 22 question whether items 2 and 3 under the objectives of 23 that project were appropriate. I thank we can handle- within 24 the motion- that was made by saying tUt we would- recommend ce -Federal Reporters, Inc. 25 that level of funding, but would reqmest that Council review 203 I both of those two issues vis-a-vis the reduction of that by 'inappropriate, or by reduction 2 either 25,000 more, if that's 3 of it even further by whatever is,repre,sented in dollars 4 by components or objectives 2 and 3 of project 36i And if-' 5 we red flag that and ask that then I think we have hand@teiT 6 both the dollar component as well as those two issues. 7 DR. BESSON: If we also add to@ that@ Dr,. Thurman-.Is 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 programs- 12 that impinge on the HMO's,we should have a policy decision 13 maybe focused on these four projects. 14 MISS A-NDERSON: Do you think we will have@ &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 am running. @a-tnat,- the, 18 query that I ask myself as to where policymaking decisions- 19 lie. I prefer to ask Council for decisions'. 20 SISTER 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 mornin- 24 I just thought to myself @.laryland is going to be j@ust a 'e-Federat Reporters Inc. 25 demonstration project for the dilemia in which we found I ourselves this morning. We really had no answers. We had 2 no guidelines. And staff was very helpfu 1, but there just 3 were no guidelines to provide us. And we continue to be 4 disturbed, that here was a program that had taken an entirely 5 new turn and was in direct response to the most recent 6 directives from Washington, and that if certain components, 7 major components were deleted there would'be no program. 8 MR. TOOMEY: Sister, can I take a crack at that? 9 It would seem to be that Baltimore, Johns Hopkins and the 10 University of Maryland are doinv 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 magic words from 14 Washington were heart disease,,cancer, stroke, kidney, and 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 RMP 19 and they decide that somewhere along the line they could 20 divide the money u P. They are dividina the projects up. 21 DR. KRAWLEWSKI: With applications off the shelf 22 probably. 23 'MR. TOOMEY: Well, -ou know y they are doing all 24 these things and they need money, so where do 'you want to ,e -Federal Reporters, Inc. 25 give it to them, for what, and they don't really care. 20.5 DR. BESSON: Well, there is one other aspect of 2 this that I think is pertinent to put it historically, at-. 3 least focusing on Maryland's move in the direction of new 4 mission, and that is that a statement about their involvement, 5 in health maintenance organization reflects backtal-the- 6 RMP coordinators meeting in March, 1971 following the@ 7 president's health message, and after discussion with 8 Secretary Richardson about the new mission for-RMP, in IBIO e., 9 and the words they use is that,following presentation the 10 following montN promotion of the development of Mioll's. 11 was featured as a prime activity for RMP@l's because of- theitr- 12 experience and their close relation to. the provders of' 13 health care." 14 That was before there was an MO office -yet. 15 created. Now there is one, and now the tu-rf is- bfvk-'ng_-- a 16 little more carefully delineated and RMP no longer has this 17 large potential charge, but a more refined c@hargea.T 18 assessment of quality of care in HNIO"s-. 19 Now if that's going to be our focus r,would' -ke- 20 Council to state that explicitly so that we can be sure that 21 our funds aren't lost in the morass of fundingrdeveiopment 22 of I-BIO's. 23 'DR. MAYER: Is everyone clear on@the questions 24 being raised? The questions are being raised relative to,, Reporters, Inc. 25 as I previously stated -- relative to number 36 and number 37' in the frame of reference that I raised them, in the dollar 2 amounts that I raised them, also are being raised in terms 3 of project 41 and the appropriateness of that. And r assume, 4 Mr. Toomey, that the question relative to project 40,. which 5 if there wasn't any talk of HMO's in here I don"t think 6 this group would have had any difficulty with,. but r 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 1510-* 10 Is that the context in which you raised the question-on,40? MR. TOOMEY: Well, that's part of it. The-,other- part is that it is a statistical study, it"s part of'the@ 12 13 E&S . could be part of an E&,S grant. My concern is th@at@ they 14 have overlapped so much in separate projects., This- project. 15 40 with project -- one of the earlier projects., 16 DR. THMIIAN: Forty relates to. 35. 17 MR. TOO@IEY: Forty relates'to 3.5,, and 36,',, aniT 3-7," 18 are just two parts of the whole. And I think-my,hang-up@ 19 is that they have just divided them up. 20 DR. MAYE R: 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, Nce- Federal Reporters, Inc. 25 seemed to be sort of in an area of opportunism, and the 207 I original one, he.@. cancer and stroke was all the word, and 2 we had very elaborate stroke proposals, as I recall, 3 something that had to do with congenital heart disease,. and 4 one thing and another. The next time around,, r-have forgot what the guidelines were at that particular time,. but-the-y 5 6 responded to them also, some kind of elaborate project, 7 mechanism which seemed to me it was a sys-tem,of directors- 8 of continuing education or something of@ that sort.. And 9 now perhaps we are seeing the same kind of responsl- at this 10 time. But then there is the theme betveen-@ here@,; ancl, that- 12 is the epidemiology and statistics function,, and@on each@ 13 of those previous visits there was a question,of'whatthe@y weie 14 doing, and we were told well,, -any moment now we., are- going, t'a@ 15 have a real basis upon which we can desigm: (yur@ own@ programs-,. 16 and yet now I hear again that we don't reati-y-have anything. 17 from that, and that was a very sizeable, budget-i:tem,, 18 recall, in earlier years, and even now.. 19 And on page 14 of your re ort at th-e top-under p 20 assessment of nIeeds and resources this confuses me again 21 further. There is one statement about the site visttors,were 22 concerned that the overall needs assessment had:not been 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 Reporters, Inc. 25 contradictory, and I wonder if you can clarify-that. L 208 wonder if you can help me got a grasp of the Regional 2 Medical Program' general -- separate from whether-or not this 3 parceling out of HMO money is appropriate or not. 4 S IST.ER ANN JOSEPHINE: We.LI,,. 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 are 7 opportunistic response. 8 In discussing and thinkin- about the@Ep:Ldemiologicai 9 and Statistical Center it was my impression- that. although 10 this center had in the past been funded under core- staff-' 11 it had in truth not really been an integral uni-@t :L-rr:aore7@ Staf I 12 And I think that the attempt that is made at the-; present'. 13 time with the appointment of a new director,. Dr,k., @on ilordis@, 14 is to achieve the objective of having some, of the, erffor-t@. 15 what percentage I wou ldn It be able to! determiner but,- t-o-! 16 have some of the effort of this center provide them evaluation 17 spoke n-. of-' as - and the planning types of services that they had 18 being provided in-the past. We could not ident.ify-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 answerEr 'your question 22 And I don't know, maybe Harold would you:want to comment- 23 on that? 24 MR. OIFLAHERTY: I think basically we went there 'e -Federal Reporters, Inc. 25 with the concern that we could not really see the pay-off 209 I of the Epidemiology-a:nd Statistics Center. At least some of 2 us left there having thet suspicion confirmed;. that really 3 we were unable to tells A. was the center an integral part 4 of the program, and B, how had the results of'i-ts activities 5 affected the development and implementation and decision-- 6 making process of the Maryland Regional Medical Program. 7 In querying the chairman of the Reg:LonaL Advisory 8 Group with respect to how decisions were made, hL- informed 9 us that priorities, goals and objectives were:se-t vis-@-vis-gr(up 10 discussion, and did not really utilize t@he process as. 11 delineated for this center@. 12 So we were concerned as a site visit team not-. on@iy@ 13 -with the effectiveness of the center and its-- out-put,. but-,@ 14 also the Re-ional Advisory Group did not real.Ly.- aomar- to-@. have 15 a logical reason d letre for decisianmaking,.. Eio-i thersfy--- wer-e@ 16 some of the re ng. really- from asons we went into questioni 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 was7-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 makin-docisions other than through the process of'group@ 23 dynamics.- 24 also SISTER A.NN JOSEPHINE: r think it"s, fair to-%say 'e-Federal Reporters, Inc 25 that many of the site visit team when they le;f-t felt I somewhat uncomfortable about these recommendations, but 2 having no guidelines to make decisions about appropriation 3 of funds for health maintenance organizations it's very 4 difficult to deal with these kinds of problems, 5 DR. WHITE: My 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 the-y@ were-n@l'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 JOSEPHINE: Well, I think wherever there itil- 13 any discussion it was very difficult to get a review of 14 anything that was being done or -had been done. Everything- was- 15 described in t and how alL theme things erms of the f uture 16 would fit in, and then Dr. Daven kept@ coming back. to. the 17 point that they had the responsibility to form. thi-w network 18 of HMO's in the state of Maryland, and it was quite a 19 diversified group. 20 MR. OIFLAHERTY: One of t&e problems, I think, that 21 we see the HIIO 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 rif t over there between the @ and the 24 two medical schools, particularly vith respect to who would Ptce- Federal Reporters, Inc. 25 receive the tissue typing project @ce there was only one All 1 tissue typing project given out, and it almost caused the 2 Battle of Armagetta. Nevertheless, what they did was 3 HMO's became a very popular mehcanism to have everybody- invaiv 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 P"*s role. It@ was kind- 11 of a hit and miss approach to HMO'S. So the'L72,,OOO@ that 12 went to Maryland was really just literally - and some of 13 you on the team may disagree, but we talked about tblw 14 appeared to be a mechanism for appeasing this medica.L school- 15 since it didn't get one of the tissum.,@ typing projects-.. 16 DR. MAYER: Well, what's @ pleasure? There@ is a 17 recommendation on the floor with modification already, 18 incorporated in it. I think one of the messages that is comi-nl,,! 19 through to me loud and clear, which I assume is coming- through 20 to staff, which I assume would be tTmslated to the Maryland 21 RMP, is that E&S Center has got to become incorporated as 22 a useful device in ihe decisionmakivz process of the Maryland 23 Regional Medical Program or it's going to be oat of business 24 at least as far as funding is cdnce,.xned. Ace-Federal Reporters, Inc. 25 NOW what beyond that do -ym want to put as 212 I stipulations o n the motion other than the ones- we already 2 have? 3 DP,,. WHITF,: The motion is for one million two 4 nine something? 5 DR. MAYER: The motion 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 HNIO 10 MR. PARKS: Sister, may I ask,you a question?' SISTER ANN JOSEPHINE: Yes. 12 MR. PARKS: This concerns a couple of things. W@ 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 rather wide, reputations-,, trhat 16 they were missing or not reaching the rural population of 17 Maryland, and did you see any -- this doesn"t- comer through-@ 18 clear. There is some compromising language in@several places 119 in this report. Do you see any manifestations of what is @20 categorized here as regionalization? 21 As I go down this and go down the itemization here 22 1 am almost at a point of wondering whether this program 23 really shouldn't be put on notice that some more substantial 24 critical changes be made within a time limitation,, that only- kce- Federal Reporters, Inc. 25 a conditional funding be given this program, and a short 213 review of the progress. Was that at all considered? DR. MAYER: well, I think 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 rights 5 there are two years in which to meet some of these conditions to come back for a valid triennial request. 6 7 SISTER ANN JOSEPHINE: We felt that b-y@ thL- time ther. 8 word got to them really they would have six months tcy@puti: 9 something together. Is that right? If we did it @st@ 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 Mary-lan-d 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 just'if-y@their, 18 program; that by the time they get 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 possibly 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 by 24 the group, and there were a number in the group-who went ce-Fedefal Reporters, Inc. 25 away very uncomfortable with this. I think there was question 214 I about the regionaliztltion 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@ sti--L.,I. from 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 inroived,, but-whether, 11 this represents a move toward minority groupineeds w@ 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, r. wou-Ld-.1 16 imagine the vast number of people, aside from-those few@pockets 17 close in here, Tobbytown and some piaces, L@ that,, where the.: 18 underserved populations, especially minorit,y,populat.ions which 19 are not served -- they are not underserved,. they are not 20 served -- St. Mary's County and various other places, where 21 they are not reached. And this is why I asked whether, -you 22 got a feeling that there would be a kind of movement toward 23 reaching out further. 24 SISTER @. JOSEPHINF,: I personally got the fbel'i:ng@ t-h@Lt ce-Federal Repoiters, Inc. 25 there was an effort being made to move out in,that direc a I and probably some small successes were beingachieved. 2 MR. PARKS: Was this one of the pro-rams, in light tw 3 of the information we got this morning, that was reduced or 4 affected at all by prior funding reductions? Do,ve,know that? 5 DR. ANCRUM: I think this has been.a problem.for-the. last two years,,_that most of their efforts have been concentrated 7 in the Baltimore area with very little involvement of ther- 8 rural or the outer areas. 9 MR. PARKS: Right. This morning I'heard7 that a 10 number of areas were affected a year or so ago by-reduct.lons- 11 in appropriations, and now that there is a s@urplus that has 12 developed or an increase in appropriation,, the ap ,placation 13 of them administratively would be first tolthose. programs- 14 that fell into A, B and C categories automatically in@terms- 15 of awarding certain kinds of funds. If we are ;hereF PiLi soi ie g 16 limitations on the program in-this particular review L think 17 also we ought to put an embargo on any added rise it 18 administratively. 19 DR. MAYER: Yes, Judy. 2 0 MRS. SILSBEE: Under the circumstances, Mr.. Parks, 21 this region is just being reviewed, so the level that comes 22 11 be what we are bound b,y@ but of Council wi 23 MR. PARES: This morning Dr. Margulies: explained 24 that there was-- ce - Fedefal Repottefs, Inc. 25 MRS. SILSBEE: Only up to the approved level-of' council-- MR. PARKS: I'm sorry? 2 evel of 3 DR. MAYER: Only Up to the approved I 4 Council action was the qualifying statement of the add-on 5 even in the case of those that were reduced.. 6 MR. PARKS: Do we know that level? 7 DR. MAYER: Well, this is what we are arri-Ving-, at@, 8 and what we have said as part of the motion was a mi-LI:Lon 294' 9 plus possible further reduction dependent upon@interpretation@ 10 of IMO. And that's a level that is about 300 t(y@4001thous&ncl- 11 below the level that they are currently functioning-.. 12 DR. KRAWL;EWSKI: Add-on not withstanding. 13 DR. MAYER: Well, further comments am. t'he@ mat-ibn?"@ 14 We will have -- just to remind you, we wou-@id, have the 15 opportunity, of course, of the aanivers@ary- review, even-. if-' this-,, 16 is passed to get some feel for what kind' o-f progress-@ has- be en 17 made in this, and another opportunity to put that- Uast six: 18 months of shot into them in case they don"t hear- the.- message 19 very clearly 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 MISS ANDERSON: I would like, to hear- it speJLied out 23 more clearly more community involvement should- be :Lm. regard@: 24 to these projects rather than a package deal by- one pe-rson @ce - Federal Reporters, Inc. 25 or one organization. 217 I DR. MAYER:- -Okay. Further comments? 2 SISTER-ANN JOSEPHINE: I would like to-make.just 3 one other comment. I think that it applies to mayber a number 4 of Regional Medical Programs,, and that is that I think't-he, 5 group needs to be very conscious of progra,@-,where@there is- 6 such a rapid turnover in coordinators,. because this precludes 7 any kind of continuity of planning and continuity of'effbrt-,, 8 and it is really difficult to evaluate the@ progress.made byr 9 a program. 10 DR. MAYER-. They need to provide a coursiy, like- I'- 11 have tried to institute in my iacU'it-Y on the care@an-d-aurture.- 12 of the dean and how important that is., They@need-'one for, 13 coordinators. MISS KERR: You are recommending- not. funding,,-, the- 14 15 developmental component? 16 SISTER ANN JOSEPHPRL-@ That"s- right.-., 17 MRS. SILSBEE: Does not the- comm:Lt@,tee haver! t@he,- 18 prerogative to ask, to see this application a:rter-, one- ypar? 19 DR. MAYER: Yes,, I would assume that we dty,,.and I-@ hM 20 hoped that that was picked up as the intent of'my comment. 21 MRS. SILSBEE: It wasn"t. 22 DR, MAYER: All right. Do you hear us now? 23 SISTER ANN JOSEPHINE: It- see@ to; me- i-.f, we. could- 24 work throumh some of the problems presented@by,this particular ce-Federal Reporters, Inc. 25 Regional Medical Program we would have the basis for other I decisions that would help us out. 2 MR. 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-thin@ 5 from other federal programs that might be supportive :Ln.some- 6 of the areas in which these programs are weak? 7 ask, that, again?-- SISTE.R ANN JOSEPHINE: Would you 8 BM. PARKS: Yes. Did you find an-y -- someone 9 mentioned here that the universities programwide-are working- 10 a number of developmental areas, and that this-apparently was, 11 one of the areas in which they f igwed , 'you@ know,,, vm- would-' 12 just treat this as a particular thing and let those 'unds 13 deal with HMO'S. I believe that was the suggestion-.. But'. 14 ,in light of this I would assume that there is- a-piet,hora 15 of federal involvement in d if ferent kinds o-f fund:Lng7.@ of@ 16 medical programs and medical activity, extension services,,. 17 experimentation, the development of physical and human- 18 resources to provide medical services. And:I would assume- 19 that these two universities are really the heart of it i:n@. 20 the state of Maryland. 21 I was wondering whether -you found that there was any 22 coordination either at the federal level or in-conj-unction 23 with the operational level at these universities,that:you 24 would tend to find a meshing so that some of the weaknesses" ,ce -Federal Reportefs, Inc. 25 that you may have identified here, you might have other 219 resources , either -federal or private, tied in to those 2 universities that could be identified to help strengthen. 3 1 mention that because I am pretty sure that the 4 federal establishment, and a large part of it in the medical 5 area comes from HEW, should really be involved in this i-n- 6 a way that one program is not saying this is weak., and ther6'8 7 some other technicians that really have &'responsibility,. 8 primary in some cases, exclusive in others, to do-s-omel of' 9 jobs that we are canning a program for being either 10 unable.to do or are not doing, 11 SISTER A.NN JOSEPHINE: I think that during- our- visit 12 we were not able to -- we didn't identify things. Now 13 probably we didn't probe deeply enough into it,. an4T- in-- the@ 14 length of time that we were there it just wasn.1-t possib-le@ tcv, 15 clarify these areas. So I would say that I really- dcny"t 16 know whether this is true. But I do kmov this from my, 17 experience in other areas where there are a number-of f'O-dOx--al@' 18 programs in operation, one of the disturbing features that 19 I continue to encounter is that sometimes federal programs 20 functioning within one institution or a neighborhoring 21 institution tend by their guidelines and the way they- develop 22 to pit one program against another one rather than to 23 compliment programs, and I would be surprised if the 24 situation were any different here. this is- probably one @ce-Fedetal Repofters, Inc. 25 whole area that we talked about needs to be explored@. MR. PARY.S: Well, if it is possible I-think we ought 2 to pass this on for advice because I think this would be a 3 tremendous help, not just from our standpoint, but from t.he- 4 standpoint of many of these programs operationally.in 5 terms of strengthening, supporting, reinforcing@what they 6 are doing, to make sure that these things do in fact 7 compliment one another rather than being antitl,-e-ti-c.al.. 8 DR. MAYER: All right. Jerry. 9 DR. BESSON: I think that's an important- enough 10 point that Mr. Parks raises that particularly since- the now-@ 11 Deputy Administrator for Development -- is that, what 12 Mr. Reesols title is -- represents a change ia the- cfrganizationa 13 format of HSH14A, so that I.P.10's,National Center for Health. 14 Services Research and Development, RMPS, Hill-Burtarr,,, and 15 Community Health Services are all put into one pack-age 16 for this kind of coordinative effort. 17 However, it may be that the political ex:tgencies- 18 of program development and the historical aspects of each .19 program being relatively autonomous, it may be that each 20 program should be encouraged to do the kind of coordinative 21 thing on the federal level that is implicit in Mr,. Parks' 22 remarks. I think it would auger well for the periphery if. 23 the center can show some leadership in this regard rather 24 than protecting their very parochial interests as they have- @ce- Federal Reporters, Inc. 25 tended to do inthe pasto and probably we see evidence of doing now. 2 So I think it might be in order for us as the 3 Review Committee to recommend to Council again that a clear 4 statement of a coornative effort at least as far as HMO's are 5 concerned, area health education centers, manpower 6 utilization a clear statement be made by Council as to 7 how RMPS efforts might best be coordinated with other- 8 agencies that bear on these questions, 9 M. MAYER: Got it. 10 Other comments? 11 Yes,, Joe. 12 DR. HESS: One further question. If I understand the proposal, it is 1.294 possibly less which may,brin- i-t 13 14 down to the neighborhood of 1.2. They are current-ly-funded@ 15 at 1.6. 1.7. Is this cut in funding, which is reatlly- substantial over current levels, is this going-ta ao-,an-y- 16 17 real damage to the pkogram? 18 DR. MAYER: They have already programmed:in.the 19 phasing out of about $800,000 worth of that anyway-.. As-lie-ast 20 as I read the-- 21 DR. HESS: 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 ANN JOSEPHINE: I got the impressions and- ce -Federal Reporters, Inc. 25 I would like some of the others who were, there to coment--- ber 36 1 but I got the impression so far as the project-num 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. Maybe they couldn't move as 7 fast. But they are phasing out the projects that I'would ber- 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, let me suggest that we take about a 17 five m]Lnute break at the outside just to get up-and@stretch-. 18 and clear our heads. 19 (A recess was taken.) 20 DR, MAYER,: Could we get started, pleasO? 21 Lot me suggest that what I would like to try-to 22 do,, if we possibly can, is to get through Louisiana and 23 Greater @laware Valley before we.quit. That may take us 24 It do th t to 5:30, a quarter to 6:00, but I think if we don a ce- Federal Reporters, Inc. 25 the pressure tomorrow is going to be too great. DR. THURMAN: Could we do Greater Delaware first? 2 DR. MAYER: I have no objection to that if 3 Dr. White and Mr. Parks do not. 4 DR. WHITE: Doesn't make any difference. to,, me,. 5 DR. MAYER: okay. Joe,, you want tcF, 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 -youi, 9 can read, I will not take time to do. t hat.. 10 This region is in its third@ operational and-@ 11 submitted a triennial application for developmental compAne,@nti,, 12 requesting renewal of core-- 13 DR. MAYER: Would you spealt u@p@ ar-- use the-- 14 microphone? 15 DR. HESS: The greater Delaware Ta;.U-Ley- regXon: 16 includes the area around Philadelphia And@ portions-@ of' 17 Pennsylvania, reaching up in the @a of Scranton- and' 18 Wilkes-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 organi'zat.i-on- formed:- 24 by institutions of higher learning In the Philadelphia areas, ce - Federal Repof ters, Inc. 25 formed to accomplish cooperative scientific project. investigations, and because this was a common meeting ground 2 for other purposes it Would mean an appropriate grantee 3 awency in order to get the Regional Me dical Programs-going 4 and provide the grantee type of support, This histor-y-has 5 also led to a rather unusual type of arrangement in.te,.rms: 6 of the overall region's directions, and I woul:d cal:L your 7 attention to the organizational diagram on page 1.3- of. 8 the yellow summary in which on the lef thand@ side wiw- em-el t ie@ 9 University Science Center as the grantee orga-nizat:Lon-.and t-hc 10 board of directors of this center shown in this diagram in a sort of parallel fashion to the, Regionat@ Advisory 12 Group, certain areawide committees which report to-both, 13 and then the executive director reports directl,-y,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- oh-airman-. of:' the- 17 RAG is on the board of directors. But it waa-elear.- u@us 18 as we investigated the policy making, dee.-isionmaking-me-chanisii 19 within this region that the real power'seems to be: i-n-th4g 20 board of directors, not in the RAG. And the board of 21 directors is rather heavily weighted with medical school, 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. @ce-Fedetal Reporters, 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 RMP 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 6 primarily on the basis of their narrative of the particular 7 project, and we don't have a yardstick against wh-ichl 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. The,y have@ acquire-d some 12 community profiles which have contributed to. the development 13 of ik data base , and this data is being used b-y@ other- 14 agencies concerned with problems of health-, an-d health- care. 15 This is not occuring on a truly regionwi de bas is@.. W6- 16 found this has been done to some extent in th-e@ c@, of' 17 Philadelphiai and a rather good st@ had been done in- the. 18 northeast regionwide which had resulted in@ some good 19 projects which seemed to be addressing themselves t.cr. the 20 diminishing supply of health manpower. But it seemed to be 21 very spotty and even nonexistent in some of these other are as. 22 We were favorably impressed with the activities re lati 23 to peer review, continuing education and manpower problems, 24 at least in some of the areas. kce- Federal Reporters, Inc. 25 The region does 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 projec.ts 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, the,y,are 7 aware of this to some extent, and are direc,ting-their- 8 efforts, at least from the medical school basis @-,rati-on-,,, 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, pa@.Li..cymaktng,, 12 decisionmaking level, we felt that this region has-much room 13 for improvement. 14 I will not go into great detai.L as far@ the 15 individual activities of each of the medical schGa@-- are 16 concerned. But I should point out that they- have divided,' 17 up the city of Philadelphia amongst the medical schooLs, an&-- 18 one osteopathic school, and they now have responsibility 19 for defined geographical areas in terms of working toi-mprove 20 the health care in these specified areas, and this we fe t 21 was a very constructive step in terms of being able to 22 organize and coordinate their efforts in this area,,. working aid 23 helping to set up neighborhood health centers and other 24 type of health care activities. And the-y-have also had some kce-Fedeial Reportets, Inc. 25 categorical projects in the areas of medical school@ 227 1 responsibility. the- othe-r, areas 2 I might also mention that some of do seem to be giving some attention 3 outside Philadelphia 4 to this, although again we felt there was room for 5 improvement. 6 ordinator has been functioning in his, position-. The co 7 for about four months, and we felt that we had to make.: "me 8 allowance for his relative newness in thts7 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..RAri to-,.back him. His major backing direction seems to come from the- bcLar-d-. of@, 12 directors. 13 There are several key staff vacancies wh-lich@. 14 exist which go back prior to his appointment- and- whiiah, have- 15 not as yet been filled, and these vacancies: Li-@it@ tm a, 16 considerable degree what he is able to doibecause- ]Ack:of@, 17 staff support. 18 Regarding the core staff,,, three of' the f'iver senior 19 level positions are presently vacant, ancT the f-ourth-wili. 20 become vacant -- or I guess is vacant now,, as of January 1. 21 These key vacancies are: the Associate Director for 22 planning and Evaluation; the Assistant Directorfbr 23 Communications and information; and. tbe, Associate Direct-or-for' 24 Program Development and Operation. one which is- now ,ce- Federal Reporters, Inc. 25 vacant in addition to those is the Associate Director for Continuing Education and Manpower. There is an acting 2 Associate Director for Program Development and Operation on 3 a part time basis, but we do not feel that this is sufficient@ 4 f or what is needed. 5 We had the feeling that the coordinator is, not 6 purs uing recruitment of people to fill the key vacancies, aS7 7 vigorously as he should. We were told that he was7 being, very 8 cautious to make sure he got the right people, a@ while 9 we concurred with that, we also felt a sense of'urgeney@ t.cy, 10 get these vacancies filled because of the obvious need forc 11 this kind of assistance. 12 We felt that most of the key health interests and@ 13 institutions were represented on the RAG. However,, there 14 were notable deficiencies with -respect to nursing and allied 15 health professions; and as I recall, there, was not real: 16 direct linkage of organized medicine to the RAG., &Ithough 17 there are a number of physicians on It. @t of the pub@.Li-c7 18 representatives we.re bankers, college 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 inpot into the, shaping 24 of policy and program direction. kce- Federal Reporters, 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 question the broader context, whether or not they are as@ 4 comfortable as they say in this situation. 5 6 As far as the grantee organization is co-neerned@we-. found no evidence that the UCSC is not providing adequate 7 administrative and other support. We had members of the team 8 specifically look at some of the budgetary reporting 9 10 procedures, and so forth,, which had been questions d@on earlijDr 11 site visits, and they seemed to be satisfied that that en&. 12 of it was being taken care of satisfactorily. 13 The region's five medical schools have,been,deeply 14 involved in developing the RUP -from the beginntbg- and stti'li 15 have a dominant influence, and our feeling was t-liat-perh@ 16 it is time for the medical schools to become. less- d-ominant@ 17 and other forces become more dominant in giv-ing- directions, 18 to the RBIP in this region. 19 The GDVRMP and CHP 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 22 consequence the R@fP area coordinator seems to be providing 23 much of the leadership and direction In this- area. But@@we 24 anticipate that CHP will pick up the slack., But as far ce -Federal Reporters, Inc. 25 as RIIP's responsibility is concerned they seem to@be doing I what they can to cooperate. They have established- a various 2 mechanism for obtaining CHP review and comments-on 3 applications-. 4 We found that there has been considerable data-.. 5 gathering in the region by the medical schools@., T-hery.,@ do-, have 6 an epidemiologist consultant who has worked with@the RMP and 7 has performed some studies,, but again. this: isF- atifi:L- 8 bit spotty, it is not a general thing', and we berlieve that. 9 this is an area that could stand considerable strengthening. 10 As far as management is concerned,, we@have mentioned I I the organization as far as the medical schook res7ponsr-i-bil.ity,,- 12 in Philadelphia. They do have a coordinating commJ-ttee-whic,h 13 is comprised of the RTEP coordinators irr, 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, coordinates 16 activities to this extent. 17 The Associate Director for Goimuni-ty@ ArfAii,.s- 18 is the member of core staff who is responsible- for,,working 19 with the area coordinators and providing-.L@iaison, and-we felt- 20 that perhaps there might be some improved strengthening 21 and coordination between what is going-o-n-in-care 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, Nce- Federal Reporters, Inc. 25 -andin some instances almost totally lacking, of' sow of the projects which we reviewed. 2 The region recently formed an evaluat,ion-committee 3 which met, and we reviewed the minutes of meetings of this 4 committee, and this committee very quickly-identifte,d 5 this deficiency and made some recommendations to@,ther,-RAG' 6 concerning this. But it is doubtful that their recommendations 7 can be implemented until they get the evaluation-pemon--on 8 core staff. 9 As far as the program proposal is concerned-- while 10 it may have a number of merits we do not fee,l.:Lt has7the of their- needs-- qualities based oh a systematic assessment 12 and a system of defined priorities, and as-a@cons ueln 13 suf fers f rom the def iciencies which arel a nat@ural'., tre@nd@@ of-'eve.,) 1 14 resulting therefrom. 15 An example, one project in which,, we@ felt.. this was 16 illustrated was a project of pediatrics resp-krat@@-- care 17 in which the project had been replicates irt@ & number- of- 18 hospitals and the' were planning, to re.pticater it several y 19 more times, and the people from the project were there and -20 we spoke with them, and we asked them - they had- been in 21 operation for three years, and we asked them what iinpact-they 22 had had, if they had any indices of the effectiveness. of their 23 programs and whether or not they really-knew whether the-. 24 hospitals where they wanted to disseminate it really needed 6ce -Federal Reporters, Inc. 25 the program, etc., and they had really no information, the-re 232 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 RMP is their team education, 6 program, part of which is related to peer review and@to@t.he 7 model of quality of care assessment developed by Dr. Brown,. anl 8 which is one of the strong areas in this total program,,, and 9 medical schools are quite involved in this endeavor,.. And- 10 on this particular score I think they are doing reasonably i 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 receivin- as much attention and- 16 consequent funding as might be appropriate if one tooked-at@ 17 this on a regionwide 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 attempting to strengthen these 22 areas; in this particular category they seem to be moving 23 in the appropriate direction. 24 As far as other funding is concerned, I have already kce-Federal Repottets, Inc. 25 mentioned that they do not have a good record of phasing out and planning ne-vi funds to support RMP initiated projects, 2 and they do not have a firm, strong policy in this@area. 3 Is Dr. Hinman here? 4 MR. PETERSON: No, he is not. He had, to@ go- to. 5 another meeting. 6 DR. HESS: There were some renaL disease projects 7 which were a matter of particular concern- and@ Dr-., Hinman ivas@ 8 a member of our site visit team and paid particular-atten@t-io@n 9 to these. 10 There is not a well developed regional kidney 11 disease plan, although there are active transplantation and-- 12 dialysis efforts goinm on in the region. But the@ fieeij-ng was@ th@ cx 13 this region as far as developing a well thought out,.caref@illy: 14 planned regional approach to management of@kid'ne-y disease, 15 just had not achieved it yet, and this consequences for,, 16 the recommendation that we will get to. in a, moment.. 17 Another particular area that we- looked :Lnta7 w Is- 18 action which is being pursued by various peopie-in t e, s@a e@ 19 of Delaware to form its own,RMP and secede from the@Gre-ater 20 Delaware VaJLJLey, and this I suppose has had its impetus 21 from a variety of sources, including the Governor,. and we 22 understand that he has had some convers:ations@with.people 23 here in Washington, and so on, and for various and-sundry 24 reasons are thinking about trying to like all health related ce-Federal Reporters, 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, and we asked Dr. Cannon to come down 5 from Wilmin-ton to talk with us to see what the view of the 6 RMP people was in this business and seewhat light thery, 7 could shed on this problem from the standpoint of RMP,, and- 8 we were told that there was a fair amount of dissatisfaction 9 on the part of the RMP group in Delaware,, feeling that the-y@ 10 perhaps had not gotten a fair shake as far as- both funding 11 as well as participation in policy setting, dec@isionmaking,. 12 et cetera; and as a result they were really rather 13 ambivalent about this secession movement, and they 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 the:y really,- had'... So.L 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. Wolf, the chairmem@ of RAG,. and Drt.. Wdl'lman,, 24 the RMP coordinator, and expressed there frankly some of- the ikce-Federal Reporters, Inc. 25 current concerns which the site visit team shared about the tions about the relationship between 1 program, We raised ques 2 the board of directors and the RAG and the representativeness 3 of the board of directors of the regionwide concerns, and 4 suggested that they re-examine that relationship and thiEr whole 5 question, and see if perhaps they might have some other 6 thoughts about it. 7 The second recommendation vhfLcti we made to@ thew was 8 that they give high priority to f illing the vacancies an 9 core staff, because we just don't see how this region 10 can function very effectively with the s@rtage of key- 11 personnel which they currently have- 12 We called attention to the recommendation of their 13 own evaluation committee made in tbLn summer of "711,, and" there- 14 also was an ad hoc committee appoitftd to study a special. 15 report prepared by the Arthur D. Little Company who, 16 came in as consultants to pursue a @agement study- or@ 17 organizational study of the region,.md really read back- to, 18 them the recommendations of this comittee that they give 19 attention to setting goals, objectiws and priorities of 20 e that we came.up the regional plan,, precisely the sawr id as 21 with, and it was interesting that ttUs came as rather- news 22 to the people that we had discovered this and were feeding ba(k 23 to them information which was alreaW currently available. 24 And I would judge from the reaction on the faces they were kce- Federal Repottvs, inc. 25 probably going to go back and read i@e reports a little was in them. more carefully to see what 2 We felt that when attention had been given to the 3 issues of the management from the RAG level, the setting 4 of goals, objectives and priorities and when they look. again ps can address 5 at their total regional situation they Perha 6 themselves to this secession movement going on in Delaware" not a necessary 7 In the view of the site visit team this is 8 any standpoints would be an undesirable thing- thing,, and from m 9 to try to carve out a separate RMP for 600,000;peop.Le:when 10 really Philadelphia has many of the resources and they- already 11 have established relationships between Wilmington and Some, 12 schools in Philadelphia, and so on. So that it medical 13 still a repair-able breacill. seemed to US that this was 14 overriding considerations at the assuming that other more 15 in to@ intervener'. G,overnorts -level and elsewhere do not come 16 But just looking at it strictl,y from t. he EMP- standpoint, in our minds this was on-s7,, try:Lng- 17 of the twu 1OPti 18 to beef up and more adequately attend to the, Delaware problems,. 19 it was preferable to secession and the cre-ation.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 her-. clear that the resources of medical.,schools and ot 24 irstitutions are actively involved in RMP activity-and have, Okce - Fedefal Repoiters, Inc. 25 contributed much to what is going on there at the present- I time. -Some of the activities are beginning to have a 2 favorable impact on manpower utilization, ambulatory-care-, and 3 health care delivery problems. Planning in the inner-cit,y by 4 th@ medical schools appears to have real potential for-the 5 f uture , and they are very much involved in this:., 6 Subregionalization is under way and has potential fdr,the 7 future as well as important benefits, alre:ad@y-apparent,, 8 especially in the Northeast area. Now that"s ther piuff- Sides 9 of the ledger. 10 On the minus side, in Summary-.,, we found' the- absen@ce- 11 of a well thought out regional plan. We have already 12 mentioned the board of directors and the RAG'-. the I'ack@of@- 13 minority representation, the high number of central carer 14 vacancies, the inadequate evaluation, the under, utilization, ds 15 of avilable data in assessing nee and the-program"%.-.poo@ 16 record for phase out. 17 Now as a consequence the team@ felit- that. tliitr7 region,- 18 was not ready for,triennial status and felt that the-re 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 developmen tal component. They are currenti- operating something y 24 close to $200,000 under their approved budget, so we felt that kce- Federal Reporters, Inc. 25 there was some flexibility within this figure of 1'..9-fbr a zoo it wouldn"t I certain number of feasibility studies, so 2 seriously impair them. 3 We felt that whatever report goes back-to them 4 should attempt to enforce the points that were@ made-i-n-the 5 feedback session. 6 We were not in favor of the expansion of' the: 7 renal disease patient support project orl the initiation o-F' 8 the demonstration and evaluation of chronic hemadial,ysis, 9 and the proposal for the school of radiotherapeu.ti-@, 10 technology was contrary to RIIP policy. 11 as for one -year- fundi:n@ at a@ level So in essence it w 12 of 1.9. 13 ay. Bill, cements?, M. MAYER: Ok 14 DR. THLIR.MKNT: I'm Just less tactful and- ev@yt-hin@ 15 else than Joe, so I will just add, a few- thingw@., 16 I think there is very little relationship, that- we,- 17 could define between the RAG and the grantee- agenc7y--.. Tliat-lis@- 18 a vpry nebulous thing. Without the board of directors 19 I don't think the RAG would know where the grantee-agency was. 20 I would emphasize again 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 talking to a machine, you got $kce-Federal Repoftefs, Inc. 25 evaluation, project approval and advisdry@ 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 along. 3 ppte 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 of 7 these really have been well thought out regional!ly-,are, 8 well planned or anything else. 9 The planning studies in reference to.-. the e-ore@ s t a-f f 10 and the medical school units theoretically-are being done by 11 the coordinating committee established between the@core.st-aff 12 and the medical units, but those are not broadbased-,,the-y 13 don't work well together,, they don't know what each oth@.- 14 are doing, and rather than initiate they re5pond@,,and' 15 that's very much of a problem. 16 The physician who is vice@ c,ha@iLrman.; o:r the. RAIT, who- 17 happens to be from one of the outlyino., areas,,, d-:Ldn-Ilt-- know- 18 half of what was being said. He said that they-were really 19 not truly involved. He 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 as Joe indicates, that"s one of the more ,e- Federal Reporters, Inc. 25 positive features of what they have, because if'that@-we.re to ;d4U I work then their regionalization would really go we 2 They happen to have one good politician who is a regional 3 coordinator, and he is doing a superb job of getting Mr..Flood 4 into the act and everybody else. But the rest of them are'r 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 Toe 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 RMP that means something to everybody. The-y reaii-y,jiist 11 don't have priorities. And I can't emphasize any- more- than 12 Joe has how weak this core staff is, and they real-Ly- just 13 Are -- something has to be done to shape that groul3-up 14 or else it will continue to be five or six Li@ttie RMPIS- 15 running all over the place under the framework o:r on(L RUP-@', 16 Despite all those things, I think there%are-some 17 strengths there, as Joe has indicated. But :Lt- wou,.Ld: 18 appear to me that it was time to really draw a few lines for 19 them and make those lines reasonably definite., B.ut I have 20 a lot less tact than Joe. 21 one other positive point, they have used a lot of' 22 bgrants developmental component money by small su 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 kce-Federal Repoftefs, Inc. 25 project going which has been developmental component money, 241 and they will pick- up money here, there, every- place e Lse. 2 But that has served a useful purpose as they- have begun to put 3 some guts into the core staff which they haven,lt had in the 4 past. 5 That's all I would add. 6 DR. MAYER: Leonard. 7 DR. SCHERLIS: 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, 11 as I read this, a project which they will continue to 12 support would be those which are really outside the- initial 13 period, coronary care, and as I turn over the shee:t@some 14 of the pulmonary, etc. In other words, what wil.Li they; 15 really be doing with that 1.9 million d(yllars?' Are- -you- 16 making-your message to them clear at this point,, wkt.U the-y-be 17 putting that money into the same old Oraj.er-ts-,, 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 doink now? 21 1 view them as having a couple hundred thousand 22 dollars thrown into the developmental components., If 17 23 read it correctly -- well, that's why I need -your help in 24 defining how -you are suggesting they spend that money. Ace -Federal Reporteis, Inc. 25 DR. MS: These projects that you see here are I indeed-ongoing projects, some of them go longer-than we..would 2 ordinarily like to see them go. But at the same time r don't 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,. anct. 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 10 written down here, but Dr-*- Watkins from the Councit raised 11 this point, and I certainly concur with it,, that this-regio-n 12 should have ongoing RI"S staff contact to help make.sure that 13 the message is interpreted to them so' that@ if they- Chooser to- 14 come in in another year with a triennial application t.hat@ they 15 indeed do the h order to,be- ready, omew6rk they need to do in 16 for that. 17 But in fairness to the people In the commun@i-ties@who-, 18 axe counting on this funding we just didn"t feet.it was 19 fair to them to try to cut that back too se@vere-1-y@, 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 22 some of the small feasibility studies that they@can obtain, 23 and their general approach is consistent with the way-the-y 24 manage things in terms of the RAG,and the way they determine @ce- Federal Reporters, Inc. 25 the overall program needs; etc., is not as systematic and Iclearcut. as we would Like to see it. I guess my problem is instead of 2 DR. SCHERLIS: 3 seeing just one or two projects going beyond the three Year I would hope that 4 period you see a whole array of them, and 5 they mLght receive very strict and harsh suggestions as far 6 as how to direct some of these funds. In fact, I would 7 be in favor of literally telling them, you know, we@ ctan 8 support 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 coordinators indicating 12 the exact specific areas of concern. I understand that has 13 been modified, is that strue? 14 Can staf f help us on that? DR. MAYER: 15 DR. SCHERLIS: I was caught in one of those I I " 16 programs of ultra detail communications which went back,, ancT I if 17 was curious what the present policy :is. 18 VOICE- -Are -you talking about technical aspects o-f' 19 individual projects? 20 DR. SCHERLIS-. A very frav& discussion of what t 21 site visitors have Stated in detail. How much of that is now 22 goin- back to the coordinator? 23 MR. CHA.MBLISS: Principally that goes back now- in 24 the form of the post Council advice letter. There have been Nce -Federal Reoorters, Inc. 25 before, though, some rather frank discussions with Greater I Delaware Valley, Dr. Margulies has been there along with 2 other members of the staff, which included Pete Peterson, IC 3 was there, and others of us, and there have been so me rather 4 frank discussions with them. 5 DR. SCHERLIS: In writing or-- 6 MR. CHA!IBLISS: I believe they were f o-ilowe-d by 7 the visit was followed by a letter. 8 DR. SCHERLI8: I think this is a vital concern here. @9 DR. PERRY: I am greatly concerned and T am happy 10 you mentioned the lack of allied health representation... r_:r 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 Uaiversit-Y-O:r 15 Pennsylvania, one at Hahneman. Here are resources, tLhat@ n@d@@ s-c me 16 kind of a voice and some kind of relationship,to,a program 17 that is spending that much money, but the-.r are not tnvolv:Lng-@ 18 them. I know in 6ne case Dr. Frank Houston has gone 19 in to RMP asking to be involved, and they said "thank-you." 20 MISS A.NDERSON: In the recommendation, too, where it 2 1says ,.lack of appropriate representation of aiiiiod-hecalth,. @22 minorities, and true consumers on the board of directors and 23 the Regional Advisory Group," they should also say "and staff'." 24 ace-Federal Repoiters, Inc. DR. MAYER: Right, and staff. I am trying to 25 you know,,,if I were Martin Woliman, who has four o@ five 245 vacancies already that are thereo with a couple-more that 2 are going to appear evidently, and I am told t-hat.the dollars 3 1 have for mext -year are essentially the same. as- the- dollars 4 1 have for this year, and I have got six- months-- to,tur-n- t-he@ -ap roved f nding 5 program around and then I am out of any p u 6 anywhere, and I had a little bit of difficulty because-I--am 7 new trying to recruit those @ple, and now@r-haver-got-& 8 new message which is there, and the only thing.-that I'have-l- 9 fact that RIM nationally- got got working for me is the 10 30 million dollar increase and at least there. is- a gpne:ra-14 11 feeling that maybe it isntt going to, die aftera all,, i-t is, out ;he 12 in the hustings, but that's all I have got gping@for me., My 13 program sure looks like it is going ta7 die andf tho@.@ bright- 14 people I am trying to recruit said what,, the@ Grerater Delaware 15 Val ley IUE) -7 now I don It know, what, k-i-ad', of ahances.--- her, has- 16 got in six months, which is what he reality, has-,, to-,- 17 initiate another grant application ta come in.,her-e- that-@ is;- 18 different than this and to create, a program in@six:mont-hs@ 19 that is different from this. 20 on the one year two year I guess I am caught up 21 approach issue in terms of the chances to do this job-. 22 DR. IESS: I must say I have great personal regret 23 in not being able to recommend more funding because I't-hink 24 this region is underfunded in relationship to what should be ce -Federal Reporters, Inc. 25 o make this done there. And so I am most reluctant t I essentially a level- of funding recommendation end 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 ra@ing- is should, wer 6 make this a two year recommendation irstead of' one in order 7 to give the region, particularly the, coordinator-,, a Little- 8 of recruitment I am certainly i@ more to bank on in terms n 9 favor of that. I think we need to do anything we can- in-, 10 order to strengthen them and give them the assist they- need 11 in order to build an effective program@ which- will. q!uaLify, 12 them for the kind of funding that I really believe they 13 should have. 14 DR. MAYER: To what degree do 'you-, think- t-hose@ 15 medical schools understood that whether that, RMP@ is- going. tol 16 survive or not is dependent upon hoftng a, strong-, centr.&L, 17 core staff , and to what degree are thely, breaking- the@ir@ neckS:7 18 to try to see that that happens, or are they@ just glad- to. 19 keep it nice and weak? 20 DR. HESS: Well, I would be, most reluctant to 21 attribute -- Bill can speak from his own point of- view-r- any 22 Machiavellian motivation to Dr. KeHow in particular,, who. 23 is the one we spoke to. The time mw, spent with him r i-ost@ 24 didn't get any feelings of this t-yp@ about him whatever; Ace-Federal Reporters, Inc. 25 and whether that's valid or not, I Ikave no way of knowing. Z47 I It's just gut reaction. But he seemed to understand when 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 the 6 medical schools together, end those were some of' the- major- 7 resources they had.- to get started with:,, but-- jxovr thatT, 8 it was on its feet and going that it was important for, 9 the medical schools to move more in the- background a-n-d let, 10 other interests play a more dominant role.. And@: he- seemed- to accept this without any real difficulty-,. but again,- I', 12 can't say how much the message got across., But. at-. least,. 13 do not have any reason to believe that this- has bee-n-I 14 overtly intentional on the part of the@ medicai@ schools.. 15 One of the problems that they@ p-aintfrd@@; o-ut@: is. t-hat@,"- off 16 the dif f icult,y of attracting qualified- professionals- t-o,-, I 17 essentially what man ee as & SOP-, @ratiion.-, wit-h,-@ y people s 18 regard to RIIP. The medical school positions are@ for.- all, 19 intents and purposes filled, and I tbLink it's@ more@ a f,unction@ 20 of the way people see RMP 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 It-- think- that s 23 there, 24 MISS ANDERSON: Are 'you sw@ggesting- a time- schedule- kce-Federal Reporters, Inc. 25 or anything for these changes? DR. HESS: No, we just said as quickly as they could 2 do it. We didn't give them any specific time schedule, but we 3 told them we felt it was important and urgent that, they address 4 these problems promptly. 5 MISS ANDERSON: These things have been brought:up 6 before over and over again. 7 DR. THURMAN: I think Mr. Chambliss has- a very 8 important point. They have been talked ta by- a lot of@ people-. 9 To go back, Bill, to what you said, r wo-uld--agree- nt with Joe. I don"t believer this 10 one hundred perce 11 Machiavellian at all. it is more a realiz@on@ that. wer- have.- .12 five RMP'S, and not one, because they are filling aL.L the medical school components,, whereas if they the. 13 devoted t 14 degree of effort to really making the core, staff oner- wha@ had, 15 a lot of clout they could do it, because we: are:@ i-,rr, @-, @-plus@ e right now, particularly where you'@ have@ fi-:v4w 16 of peopi 1 7 medical schools generating people Who C)OU,.Cd7 do-, this- wrd-' 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 RMP'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., r,,t"s just by 24 the fact that Temple is not really going to,sh-ake the,-hand @ce-Fedeial Repoiters, Inc. 25 of the University of Pennsylvania too hard.. They Will meet them once a month for-dinner, but they are not going to shake 2 their hand too hard. And that's where the weakness really 3 comes up, And that's why I think again,. to go back--to what 4 Joe saidt I would be opposed to going to@ more than oner year-- 5 because I think they have got everything they need ta make- 6 this a going operation. They have got the, demand-, they,- have 7 the support of the people around them, and everythi:ng@else-.. 8 They need to know that they can do it,,, and' r think they can. 9 DR. MAYER: Leonard. 10 DR. SCHERLIS: From a practical point of view I-@ would certainly agree with what the. Chairman', stated,,, that- 'you 12 can't go and hire anyone really of any- stature if- him only. 13 thinks he can work for one -year. Th-is has bee.ni one- of: the 14 difficulties with not just getting staff,. but of keeping- 15 staff And not th:Ls@ :Ls- the wV,- to I qOestion whether or 16 strengthen a region by telling them they, wi.Li g@ nor-@@ mon@y. 17 whatsoever unless they shape up and.at t-he@ seen, time- gi-ve-- 18 them 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, of'tdtal 22 projects about 400,000 for projects.,- And if you look at 23 those projects practically every one o-f them is, outdated 24 in terms of it has been over three yearEr,. and they are just- @e- Federal Reporters, Inc. 25 supporting them for much too long a Per od of time,, and. this@ zov I @is how -they get the request -- their operating leve I 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, s@', 4 two years of support, but knocking that 1.9 dowry and then iin 5 the second year giving them a sum that would at least:enable, 6 their core and some projects to function, because if you 7 .9 for that two years away period gave them, for example, I 8 they are going to have nothing to support unless they keep 9 going on their projects,--land that's an easy way to go-f'or it. 10 the order of My feeling would be something on 11 say they have to shape up and letts cut it down to I-. 7' this- 12 year and 1.25 the following year, if,you can reall@y-come-up 13 with a program we will accept an application year;a;fter-ye-ar. 14 At least they can hire someone f or a two@ ye@ar@ pe r iod at 15 time. 16 I think 1. 9 is high, and I think that the:y-- won' t- be. 17 able to really shape up if we don It - promise- t-herm- some- support-. 18 after that one year period. I don"t see how you can go out to 19 1 a professional person of some stature if-you want, hi-in.i@n core 20 and say "well,, if we really do well ve 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, kce- Federal Reporters, Inc. 25 whereas one year is not quite that, and neither is lff months. I But two years, you knoWp is a pretty solid time-te rm. 2 DR. SCHERLIS: I'm concerned about that I.,g, because 3 I do have this concern about continuity of ongoing project., 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- 7 because we feel you have to get some ccFre staff ta carry this-.- 8 on. I am not making this as a motion, because I want to. .9 see what your reaction would be to that, Dr@.. Hess. 10 DR. BESS: Our thought was the,y they- indeed could.' 11 begin to tackle the issue of phase out byr trying. to-. f-und some 12 new projects that they would l@ to b-y-pbasing out of the 13 some of the old ones. This would give us a means offending 14 out when we review another year whether or not they@really 15 had established some goals and priorities that,- the-y-were- 16 making operational, and we felt we needed to%give then@a 17 little maneuvering room in order to.-do t-his., 18 Now -your real question is how much.,, and :LE we cut 19 them back too much will they be able to fill those core 20 vacancies they want to fill in light of their ongoing obligation 21 to people out in the field that they have to maintain some erms of funding. 22 kind of credibility in t 23 DR. SCHERLIS: I really feel more strongily-about-, 24 that second -year of support. Do -you feel it shool@d- be- zeroed @ce- Federal Reporters, Inc. 25 in view o.f the discussion DR. HESS-.I Nos I wouid be perfectly Filling to show 2 support for the second year in order to give them something 3 to bank on. I think that's sound. 4 DR. MAYER: The request for core in the second year-, 5 that includes all components of care, central core plus. thEr 6 individual schools, is 1.67. 7 DR. HESS: Incidentally, the major increment in core 8 in their proposal as opposed to where the,y are now is in 9 the medical school components. We suggested' to then that 10 they consider keeping the medical school components at level' I I 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@ Laat Tuiy.. 15 MISS KERR: Which is a very @hoTt time., And: i-n- 16 view of the fact that so many people V!.ave been@ ta.Lki@jig@ to 17 the director, and so forth, perhaps-it vaa hard ta%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.IIBLISS: If the committee would j'ust permit 24 me to act as a volunteer here, may lsay@that in these ,e-Federat Repotters, Inc. 25 complex metroIpolitan areas where there are multiple medical I schools there are very definite problems in getting the 2 RMP going. Whether they need additional time I personally 3 cannot say.. Whether it will be additional money I-c-annot say.. 4 1 do have this feeling, though, that it centers around the element of leadership -- of leadership of a Persons having 5 6 a certain amount of boldness, who is willing to@ge.t.things- 7 moving, and I think we have seen this ver- y- candidl@y.,- expressed 8 already today in the Illinois situation, 9 So what is the element that these complex@metra.-- 10 politan areas need that we can provide, and l@' thinks this 11 element of leadership is one of the mines qua nons7; of' which 12 it will not move unless it has. 13 Now you make the point that this coordinator has 1 4 been there since July. and the- point is, reinforced- by the-@ 15 fact that he was the deputy under the previous coardiAator 16 for some time. We need -your help herl- :Ln, trying- to- f7ibd' what- 17 are the elements needed to get this kind-, of RIM,, under- way, 18 to help us examine what you think ought to be done and make 19 some recommendations in accordance thereto. 20 DR. SCEERLIS: 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. in@ner 24 core and another $750,000, $110,000 plus or minus 20,1 guess ce -Federal Reporters, Inc. 25 was the number they agreed upon, which would be centered arourd 254 I the other six medical schools. And I think one way to preserve 2 a weak RMP is to have a good portion of that-budget not 3 under his and the RAGIS domain. And as I read this my-concerr 4 would be that one message that should go backwould@be that 5 th e core should really run the RMP in that state,. and@not 6 be subservient to all the other cores- which. opeLrat4w,, and I-- 7 would assume fairly independent. And i@f they- want to-@ 8 set up projects in the other medical schools,, in one- school, 9 where Dr. Pastore is, and it his thing is peer-review and- 10 continuing education and ambulatory care which he does in 11 exemplary manner, I am sure he can-come-in@with,an@ 12 excellent project which would then be subject. to-@ tecin a 13 review. 14 1 don It think -you can have, a strong RAIP- where,- ypu 15 have a series of cores which operate, independently, a-nd@ 16 not subject to the usual type of-teehnical review,,and- I-.. thin]: 17 that Is what we are seeing replicated iiT, a;, great maffy-- urban:- 18 areas where we have a great man-y medical school operating. 19 And I would think that one message to.gat back 20 here -- this is why the system has worked so well :La 21 Chicago. Their executive director makes. it very-olie-ar that 22 he runs that program, and if a vledical school wants something 23 they work'with him. This hasn't caused any s-chism,. but it, 24 has caused an unbelievable amount of support, and-1--would ,e Federal Reporters, Inc. 25 think this is one message that should get back. 255 As I read'core, it is a fractionated, mult@icentric, 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 essenti,&Li,y correct, and 5 this is the point that I tried to make earlier@.. that-, 6 medical school domination at a number of- points i-n-t-he- 7 system is having an adverse effect on th4 reg@n,, and- it is 8 indeed going to take stronger@ leade-rsh-ipr in- to-rm@-- of @ the RAG. 9 We can't in a very detailed way evaluate the-c7oordinator 10 and the effectiveness of his function.. W@ days have, some 11 serious questions about it, but again, we re'C"gnize- the: 12 short period of time which he has been :Ln-. th@ full authority 13 position, and therefore we sort of hedged on that particu .lar 14 issue, but fully aware that this may- be part. at' t-he- CTUX 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@ arer4 @o-i-ng.Ito@lget the 18 kind of coordinator appointed, that we *du Id.- like to-- see. 19 Now maybe if the center of power shifted that.curren 20 coordinator would be able to function much more effecgively 21 because he would have a different kind of Ipower base- 22 behind him backing him up at a palicym'aking level.. 23 So, you see, there are all these dimensions that 24 handle on are very hard to get a and they@al'i directly ,ce-Federal Reporters, Inc. 25 interact. I DR. MAYR.R: Would somebody caxe to make a motion? 2 DR. @S: I will make the motion. We have made 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 -- well, they would have to come in for 7 an annual application, wouldn't they, ano ther year, another 8 site review, and so on. Is that correct? 9 DR. MAYER: No. wouldn't have to be site visited. 10 DR. HESS: All right. I wou Id attach a recommendation 11 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. MAYER: 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 f igures? 17 DR. HESS: No. 18 MI$S ANDERSON: I'm sorry. 19 DR. MAYER: 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. SCHERLIS: I did not see in the site visi 24 report specific reference to these multiple cores. @ce- Federal Repoftets, Inc. 25 would hope that that discussion would be incorporated in the I I . I 257 I evaluation of the unit, because I expect the Greater 2 Delaware Valle area will not move from where it is now y 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? Dcp -you- 6 think that should be part of the recommendation that goes 7 out? 8 DR. ILAYER: (Nods.) 9 Further comment, discussion? 10 hose in favor, "aye"'? All t 11 (Chorus of "ayes.") 12 ed? oppos 13 DR. THURI.IAN: Aye. 14 DR. SCHERLIS: I think I should ask the Chairman 15 to speak up and not move his head because that doesn:"t gcp. 16 on the tape. You expressed concurrence. 17 DR. tlAYER: What's that 18 DR. SCHERI"IS: I don't know if the tape heard you-. 19 You agreed, didn't you? 20 DR. tlAYER: Yes, I did. 21 Let us move on to Louisiwm and then we will call 22 it a day. 23 DR. WHITE: Normally I cme, to this point in@ ti.me 24 feeling fairly comfortable about ITM. I feel about the. region- ice - Federal Reporters, Inc. 25 I visited,and I have adopted a position and I try to@ persuade 258 I 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 r 4 say that because I never really got a very definite- kind of-' 5 feeling about anything specific about the Lott@is-iana. Regional, 6 Medical Program. 7 f ault because I w@ helped This is in part my own 8 by a superlative team of site visitors, including Mr,., P-arks-- 9 and our staff from here, and I guess it"s beceuse- I trie& 10 to mix business and pleasure. As my wife afid'I viewe-d-the. 11 stark,, bleak, white winter of Wisconsin ahead of us we 12 decided that perha Louisiana wit,h-me. ps she should go to 13 But I find that it's difficult to have a sec-ond'hone-ymoon and 14 be an effective site visitor at the same, time-. N#-Ithe@r one, 15 was accomplished to my satisfaction. 16 (Laughter.) 17 1 think that to view the Louisiaxr& priagram@ona has@- 18 to recognize some of the encrusted attitudes that exist@ 19 in that state. They take great pride in,their crawfish and 20 oysters, and I think that there are other shells in that en. 21 area which are difficult to penetrate or to-c-rack@op 22 You may recall that there was some early trouble 23 with the development of the Regional Medical programiof- 24 en though a past presi-de-n Louisiana, that Dr. Babatier, ev tp ce-Federal Reporters, Inc. 25 I believe, of the Medical Society, was at one@@ti@me;to,be expelled because he 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 Medica.L 6 program has a place to play in the state of Louisiana.. 7 Another problem relates to thei two s-ystems- of' healti 8 care that exist in that state. There is a s-ys-teny of state 9 hospital around Louisiana, charity hospitals.. These- h-avc- 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 curtain nor,a 14 bamboo curtain, but sort of a-gauze curtain between@ the 15 private and the Donprivate health care systems in- the-- 5-tate-@ 16 of Louisiana. 17 Further I think that the Louisiana nied7ical prog _rwn 18 has suffered, in-my view, from the sufferings of the 19 other Regional Medical Programs. Sometimes the signals@ 20 they have had from those of us who bave made site visits 21 or from staff or from the Council bave 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 ice-Fedefal Reporters, Inc. 25 of Washington alone or the Feds alme. I tht@nk that the 260 I Regional Medical Pro-grams in the context of our earlier 2 discussion today have been hanging arou@nd too lon- waiting 3 for someone to put a hoop through their nose or ri:ng,thro.ugh 4 their nose to lead them down the path. Seems taime-t 5 guidelines and messages are broad enotygii,, nonspecific 6 enough that the region should be able ta d'efine-@its own 7 s within those and not wait for specific tyt)es-of@ program 8 statements that they can voice back. Louisiana has been 9 guilty of this, and still is guilty of this. 10 But in honesty and in fairness to@them r would sa)r 11 that they have gotten into the planning of thtngs-to-la 12 great extent because this is what theywere told tcy@,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., r-t,' tw dkffLcuLt-., 16 to sort them out. They indeed have become the, jyjanning 17 body for the state of Louisiana. are'not an - action 18 oriented group. 19 But I donltvant 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 stater 22 of asking for an operational grant this would be just dandy. 23 But they are asking for a triennial grant,. ancT, t@h:Ls- has- to 24 be viewed somewhat more critically. ce-Fedetat Reporters, Inc. 25 They have indeed established goals and objectives. 261 They :both say the same thing in different words. They are 2 going to deliver better care to the medically disadvantaged,, 3 they are go.ing to increase productivity, they- are going 4 to contain costs, they are going to develop the 5 additional kinds of health manpower that are necessary,,and' 6 so on. These are the same kinds of Words that we have 7 heard over and over again. They are laud'able, to. be-; sure;. 8 but I dOD't see really any clear view as to how these arer 9 going to be implemented in the state of Louisiana., Nor-do- 10 I see a clear understanding of the priorities- for thL- actions 11 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 know that,the-y 14 have undertaken this assessment. They have the@ data,, bLt, 15 1 don't see that they have clearly used these, data, ta, predicts a, 16 goal and objective for them. 17 Again, however, I don't want to be: negative:., These@ 18 people have accomplished things. They do have@,, as IC, said@,,, 19 these data. They have used them in conjunction with..other@ 20 health agencies in the state well. They have even been 21 request6d 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 r@egarded@wi-th 24 anything prior to that. They have planned with area health kce-Federal Reporters, Inc. 25 nd State Rea-Lth. Departments;, planning councils, New Orleans a 262 I they provide a data base which are helpful to them as well- 2 as to RMP. 3 They have developed methods for studying-, 4 blems which has beea helpful :Ln-. tip immunization pro grad:Lng, 5 care in certain areas. 6 They- have been able to determined n-ee-ds; for- Certain, 7 types of allied health manpower which may be he-.LpfuL to@@ 8 Dr. Peterson and some of the others in@the-:Euture for 9 determining the programs to be undertaken, by- than respective 10 schools. They have one mark which I think, i@ herlpf'uL4. They,- 12 undertook a study of irradiation therapy,capackties in@the 13 state, and on the basis of their studies the- hospitals 14 recognized that there wasn It a need for- each: of them. to@@ 15 develop a f aciiity, there was &a adequate base@ for- career at, 16 the present time. And I think this was a a-ign:Lf-teant. 17 accomplishment. pathologists 18 They have broad support from the 19 in the state because they were helpful to t.he pathologists 20 in developing a laboratory standards committee and quaiit-y 21 controls which were applied to most of the s@tate@llaboratories. 22 and I think this is a mark of distinction,, too. 23 So I am presenting a picture that is- mi@ed@ 24 obviously. There axe some accomplishments, there7are marry ce -Federal Reporters, Inc. 25 weaknesses. But I don't think we should focus@ just, on. the. 263 weaknesses. 2 Another point in their favor is that- the-y-have-been@ 3 able to phase. outr-even though their evaluation, and- review 4 mechanisms are rather weak, somehow- or o-th@ they, di-d- manage to 5 identify one particular project at least that was-,not'Imeeting. 6 its objectives and goals and was just wasting@ money,. and., they.- 7 terminated it. 8 They have been able ta@ find ce--rtain@ kimds. of-' s-upport 9 for some of their other activities. The. H4art Posoci-at-ion:-. 10 is going to continue supporting tbLe cardiopulmonary,, 11 rescussitation program. The State Departmn-t o-f Heath, will. 12 continue to provide funding for the hea.Lth-. i-nfcyrma-t:Lon@ 13 clearinghouse project. The Louisiana Medical Socierty,- 14 indeed subscribed to and supports the diaL access- @graxa that was created by RMP in that area.. 16 ot reaLLy- repre-se-ated,- even.. Minority interests are n 17 in a token manner, and certainly not repres:ented- b)a-iic-,ve@ 18 in the deliberations that are necessary- for- theL plan of-' 19 action that is required for the state of Louisiana., They: 20 expressed an interest in recruiting additional minority an 21 disadvantaged participation witbL& view that the@y were-going-to 22 do this through the CHP B agencies. They were indeed going_ 23 to use these agencies as their s@ubregian&l:ization- o-r--- local- 24 area councils. And to me at least this see@ a dubious.-way-of @ce-Fedetal Reporters, Inc. 25 going about it. I am doubtful that the peLopia involved-. in@ CHP creation are likely to be any more concerned about 2 minority interests than has been the RAG of the Regional 3 Medical Program. 4 We saw little to indicate that black-. pFhysi)aians-@ were 5 involved, black citizens involved. We@ saw I:LttieL i.@n. ther 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@&rood 9 leadership. He has been able to be persuasive,. has bee-rr. 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 earlier 1 13 in another program, and perhaps this is a time that.this-needs 14 to be' done in Louisiana, I don't know- But r, thi:nk: her is- 15 talented man, and he is skillful, and be- has-- brought- together, 16 a good core staff. Surprisingly, their background'wo-uld,-Iead- 17 you to think they are not very capable,, but- thery-- area.. Y&,w.- of. 18 them have had any education in health fields7or@management 19 fields. One was an airline stewardess who@somehow or- other 20 got into the Region al Medical Programs, and I think is doing a 21 heck of a good 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 vis-ibi-li@ty-f-br-the 24 Regional Medical Program. The Regional Modicar Program- kce- Federal Reporters, Inc. 25 through the efforts of core staff and@Dr., Sabatier L think now 265 I is regarded as 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 care- 5 functions. There are strengths, there are weaknesses.. The@y, 6 manage things very well. They have fiscal managements which is: 7 very good. They have been subject to audit without fault., 8 1 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 that"s on@the 14 next page,, and that's the Regional Advisory Group. 15 AlthoughtLirly representative of key heaLt,it interests 16 in the state on paper, I think we cam away with the feeiing7 17 they didn't really participate very nuch. There were allie@d'. 18 health people listed, there were hospital administrators 19 listed,, there were medical school deans listed, the.re-were 20 medical society representatives listed, and so on. But it 21 was difficult for us to get a grasp of an facts that would. y 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 kce-Fedetal Repotters, Inc. 25 be likely to achieve these objectives-and goals. -They-met I infrequently,, they did not serve on any of the committees. 2 They did not function in reviewing the projects other than 3 to look at what was handed them when it f inally came to the- 4 time of a Regional Advisory Committee meeting. 5 Surprisingly enough, some of them,, r guessl,, 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. We know t,hat,,,"' bu-t- hadn't, 13 really thought that maybe they should do sometliing:about 14 the fact that they weren't doing what they really should be@ 15 doing. 16 Well" this I thinkt in my opinion.at least ---others 17 may have a different view of RegionaL Redica--L,. P-rograns- :Ln, IS Louisiana -- this-is a major weakness. This is not & 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.. IC 22 don't know whether that's even the appropriate term.. They- 23 just don't-partidipate. They must be made to;partic-lpate.. 24 And we have some recommendations to make in our@overview of kce-Fediaral Reportets, Inc. 25 the program with Dr. Sabatier when we finish. 267 I Related to this is another programpand 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-incorporater an 5 economist, an engineer, and certain other people,. 9-a, the 6 flexibility that the Regional Advisory Group has- in appointing 7 members to this is very slight. It must includtr thef- past- 8 chairman of the Regional Advisory Group,, the- med-ic@al; cente@- 9 officials, and a member of the@ State Medical Society-.. 10 In reality this group has full veto over- anyt-hing.- 11 the Regional Advisory Group does. Ww,- they, t-eFIL uw@ th'at@. 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 @ come that :L:r the. 15 Regional Advisory Group does become active.-,, does.- :E,:Lnd, a. 16 spark that gets it going, that there may- be, some-@ conflicts, 17 which comes about. There is the. one trustee.- s-tr-uctur-e- wliic,h@@ 18 likes status quo and don't rock the beat,. and@ another one- 19 wants to start doing it, there may ba, areas of conflict 20 that come about; and this relationship should be straightened 21 out prior to that. 22 Many of the health interexds in Louisiana are, 23 involved in programs. We don't see that any- a-nu o:t them- has@ 24 co-opted the Regional Advisory Grotw.., No, problems really, kce-Federal Repoiters, Inc. 25 in relating within the health stru at the- pre.se.nt@ time. 268 I This has improved, as I said, from the past. 2 The re.lationships between RMP and CHP, difficult 3 to straighten out, largely because RMP Wm been.doing what, 4 CHP would be expected to do, I think, and this is@refleated 5 in the attitude of people in the state. They- have &. blurred.. 6 image of what RMP should be and what CHP s@hou-l(f be'. And a 7 Dr. Acory, who was appointed -- and I have forgotten-,e-xacti-y,. 8 how this came about -- but in any event he was@appoi-nted 9 by somebody in authority to try and define what the-respect:Lve- 10 roles of these two organizations is to be-, and hec-onf'ussed 11 to us in open forum that he didn't really know.. And. L kind,- 12 of got an idea that he wasn't terribly concerned that it be 13 cleared up. I am not sure that he is the kind. of. person 14 that should be conductin that study. .I mentioned loc 15 al planning that we, feE..Ut that, 16 perhaps this was somewhat weak because it was. gain@ -to.@be 17 dependent upon CHP B agencies. We saw Li-ttle :Lnvol:vamnt, by,.- 18 actual citizens of the state. What ve 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 get into the health care s,yatem,;bot 23 apparently-grass roots sort of project. But we,weren @t. 24 terribly stimulated by the individual wha presented-that to, ice-Federal Reporters, Inc. 25 us, weren't sure that the concepts were entirely correct.,, 269 I 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-i-s 7 weak. 8 The action plan there really is not much of an 9 action plan. They have said that they are going t@cF, improve 10 certain things. They are going to improve health care for@the@ 11 disadvantaged, Ding ta,@ but look at what they are g 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- cente-r-- 15 in the New Orleans Charity Hospital, and they are gal-ng- 16 to create -- have forgotten a renal program within 17 the Charity Hospital system. Now they say this wUL, hei"p@, heat;h 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 the-y@ will kce - Federal Reporters, Inc. 25 go in private practice in large part, and once the-y@go into 270 private practice the relationship to the charity hospital 2 system becomes quite weak. So it is highly-tenuous sort of 3 reasoning that they have used. 4 They have created priorities which.I:wiAL read- 5 to you. The cardiac care unit is the@ number- one pri@oxity'. 6 This incorporated the spending of several hundred'thousand 7 dollars for equipment. Something having, to.@ dOF@) with-. shared. 8 services, and this is a program which. rural hos-pi,tai.s- would 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 quitel G-learly- undo3rat-and- 12 how tumor registries related to bringing bet,ter,c-are to:the- 13 rural and disadvantaged people. 14 A regional kidney program-is four,.. H6a.Lthdate, 15 information center is five. Cardiopu.Lmonary@ r-e:s-a@itat-ion: 16 unit is six. Stroke discharge planning,,., seven-;: pediatrics 17 pulmonary planning,, eight; or,6*an,,, number- nine:,, added 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 k nds 21 of continuing education programs around' the state- for the 22 nurses, the dial access program for physicians,,and-:So@on. 23 1 think I shall not go into2 further- d-e-tai:i. about 24 this. I think I have covered the points that J7 thitik-are of @ce-Federat Reporters, Inc. 25 concern to me, and I would rather turn tol D@., Parks. at-, this 271 I time before we get -into telling you what our specific-- thoughts 2 might be as to funding and other recommendations. 3 MR. PARKS: Well, due to the lateness of the hour 4 and the completeness of that report, I c-an@ agreeL with-. most-, 5 of it. There are a couple of things. that r think IC should:- 6 probably highlight. 7 There was a lot that I didn 'It sees @; that, room 8 I did walk the streets, I took the Ltinch, ha-ur% anti waJ-ke:d the- 9 streets to see something of the population,, to.@ see 10 found any kind of representatiion in that population withiir-, I I the confines of the room in which we were- a-o-nferri:ng--., I@ d@id@-- 12 not f ind it there. and I think that bas been-. covered, somewhat 13 adequately. 14 I happened quite accident@y- to: ask-, the@. black. 15 receptionist that they had about opportunity-% for- 16 advancement, and she mentioned to me that shEr@ had'. come 17 on board the week before. So I assmme@ from. that that, the-@ 18 word went out that there probably would: be- a black, on@ the- review thing and the y 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 Agriculture. He was very glib, but largely- impertinent Ace-Fedetal Reporters, Inc. 25 in terms of the information that he gave us;- impertinent not-: 272 I in the insulting sense.. but impertinent in.terms of..what he 2 was addressing,' 3 We talked with Mr. Roberts,. who is the Assistant 4 Director for Administration. He is &, very. abla- mau. 5 mentioned some problems which were fiscaL which.were 6 occasioned by late funding, and@ this w@- being unable, to, start programs and then getting mone-y@in-,the-- mi-d-d i6.-@ of_, 7 8 their f iscal year. But I think the-rer w@: s-me7- &-uggestions- 9 that would deal with that. 10 I did ask him about the question of what-her the,.-- I I and activities that they,, f undec'L@ at,- the-- variou s various programs 12 medical schools and activities throughout the-stat-w.;@with:. 13 respect to regionalization r think. they probably.- had 14 somewhe re between f ive and seven, ou-treach. proj@ct@-- that were 15 spread in different points ia the@ a-tatw.. But, he- d:id.-: indicate 16 to me beyond receiving a certificate of aomp.Liance--@they- 17 monitoring to make sure whether,the-@pragrams-7 were;, did no 18 in fact reaching the people, that they were@ de@s-i@gned-'to:, 19 whether there were fair hiring practices th&t,were in fact 20 operational, and various other things like this,.which I' 21 thought was a weakness,, perhaps not b-y-t-ntent@,,,but-by@vir ue 22 of lack of direction in that area. 23 -The RAG chairman I. thought- was- a disaster.. HO--was 24 the director of the state health system@. something like that. ce-Fedefal Reportefs, Inc. 25 He was a state official. He@was introduced,@as-a-. 273 DR. WHITE:- He was a private practitioner. 2 VOICE: He sits on several boards that have 3 jurisdiction.over the state system. I think he s:its@ on the- 4 state administration of hospitals. 5 MR. PARKS: This is somehow very- closely,- tied i-nta-- 6 that operation;-and to the ex officio appointees to@-both. 7 the RMP and the RAG, in the composition of those- by.-laws-,, there 8 is an interlocking kind of directorate re-aL-ly- which-. makes 9 up the executive committee of both. 10 There were apparently problems of turf an-d rivalry- 11 between the medical schools, and,, of course,. the.@ peceuli-ar- 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 Louisi@a, situation,, and"; 16 that Dr. Sabatier, whom I think is a rery skillfu.L. 17 coordinator, and certainly I would assume. a, ski- @,u-L poJ-:L@-.ian- 18 seems to have made-some passable accomodation with:tiese 19 competing forces to obtain some measure of recognit:Lon.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 they were almost incapable of resolution,.and 24 that they would be boulders behind which they would hide for kce - Fedeial Repotters, Inc. 25 not making certain kinds of changes that we were looking for in 274 I terms of action oriented or delivery oriented kind s of activity. 2 The thing came through very directly to me that 3 Louisiana has some very, very peculiar problems, and r did not 4 detect that they had been not only recognized,, but melt.,. and@ no%% 5 that they were in a position hopefully to,mave aroun-d-,them 6 to achieve some - other things. 7 1 detected two others things. One, that the.- design, the planning design was sort of an operational device to 9 get around some of the hostility, in addition to-l@having beeLn 10 perhaps an invited error by prior site visitors@.. The other, 11 thing was as a result of that, th heavy emphasis oE 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 off icer,,, whct-: wor-kecd@ 18 apparently by himself. And this was really the ke-y,man to 19 their outreach and their developmental activity. 20 I would say that there are a number of positives, a d I 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 shoul'd-be put ,ce-Federal Repoitefs, Inc. 25 on a basis where some of the recommendations will address Z70 I 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 r woutcr like to-- 7 voice my feelings about the renal progr@a-m tir the state-- of-- 8 Louisiana, in spite of separate or se@'-separate or-not. 9 separate funding, or whatever it might. be.. 10 In spite of the fact that the technology- 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 aiLl.of a.auddan,,and@. 15 that it relates appropriately to a center f@or, transplantat,3'mn.,, 16 and so on, and that people now onano-ther kidney- project 17 won't get paid twice by being on this@ project.,, tcio-.,, and-- those 18 sort of things, as-I view the project it really-does@not. 19 serve the purpose of the Regional Medic@al Programs" it,is: 20 going to be a syste m in the charity hospital system. There 21 is nothing that I see in it which makes it a total system@f-or 22 the state. 23 The fact that we have some documents which.indicate 24 there is some disagreement as to whether or'not-there7should @ce- Federal Reporters, Inc. 25 be a total system for the state, with th-e@feeling.th&t.maybe. 276 I there should be one- renal program for the charity and one 2 renal program for the other people. 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 times that it should go 7 back through a review process and bL- 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 s.'t-te Visitors 12 at the late hour that we met on the second day came up with-, 13 a round figure of a million dollars- They had asked for 14 a million eight, and they are curre-itly functioning at 15 about seven f if ty. We f e it that th,3% was enough to, help', them 16 -strengthen their core. It might alav 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. 1 9 ability to handle their own funds ant establish their own 20 priorities, and give us f urther evinmce to base our judgments on in the future as to whether there should not@ .necessarily 22 be a triennial RMPO but one at all dm the state of 23 Louisiana.' 24 There is a problem in retwence to the coronary- P-ce-Federal RepoiteFs, Inc. 25 care units. This was previously aMr,.oved by this body, pr3or 277 I to the time that there was any interdiction on the use of- funds for equipment. They feel that it is perfectly 3 legitimate under those circumstances for them to proceed-w:Lth. 4 this. I don't know that we should give them dlirectlon-along- 5 these lines. This again would be a measure of. whe.ther- ar- no@t, 6 they are capable of managing their fu@ and programs 7 appropriately. 8 So I think our recommendation is,, for miliLi-on: dollar s 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. MAYER: Do you want to ccw"nt about, the 12 discussion we have now had times two about the two@year 13 funding? 14 DR. WHITE: I have no'objecti-ons, t.a, that.. That, wli.L 15 be all right -- for myself. I don't know@, how, Mt,.. Pa;rks@ 16 feels about that. 17 DR. MAYER: The question be:ing, d@. we, mak@ a. comm:Ltmet t 18 for a second year -at some leve I 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-. Well, I have not really consulted with 23 anyone about a second year type of fan@ding, But. L would 24 s here I- think- it say this, that from one of the discussion ice -Federal Reporters, Inc. 25 is very true that faced with the coordination: or direction. of- I the program, especially charged, say, with a direct 2 immediate responsibility of making certaia kinds of programmatic 3 changes, having the people aboard who will be necessar-y,to make 4 creditable changes is a very important part of it@..- @,L 5 would assume that the life expectancy of a. program iz a, very,, 6 great factor involved in determining whether & person will'@Or7 Wil 7 not remain in the program. And I think witb. some o-f the 8 recommendations that we have here it might, be. ap propr-iater fbx-- 9 us to consider some figure. 10 I am not prepared at this time to make an estimate I I of what a figure should be for a second. year.. l@,' would thi-nk-,, 12 though, that some consideration ought to,be given.to@i-t. 13 so that it would not appear that we are asking them-@to@improve 14 f or one year and beyond that there is no, Light at the-. eLnd 15 of the tunnel. 16 DR. MAYER: Could you and Dr. White come, up, with- 17 a figure by tomorrow for us? 18 DR. WHITE: 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 agreement 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 'yeax.. 23 DR MAYER: Leonard. 24 DR. SCHERLIS: You knew I would;have ta,comment. .ce -Federal Reporters, Inc. 25 This is the only time I have had to say he-art all day--, and. 279 it's nice to mention that word in a c&te-goricaL area.. i. 2 do have a lot of concern about half a.jmiiiion dollars 3 going into the coronary care training, anit.. r have: concer-n 4 about the way it is described as inc,la4ing.remodeling of 5 present heart station, expanding the c@iac@ c.athe-r.-ization 6 laboratory,, remodeling the outpatient cardiac clinic-,, 7 consultation, computer techniques,, cowtin uing.. cowana-ry car-e@.,, 8 and also it mentions physicians and nu3rses.. 9 One or two things strike me. one,, e-itherr. the mail is 10 very slow between here and New Orleans,, or else the- 11 visibility of the smoke signals isntt very-, good@., But- I: 12 would think that had this been submitted. even. three, or. four@ 13 years ago that I would have had a great deal of reaction 14 to it which was negative. I think tba.t any place. in- the 15 country could come up with this, project., reg-ardleErs-- of- how,, good 16 their program is. If'they have a reaL need@for a 17 coronary c are unit that something @ the, neighorhoo-d- of,- 18 20 or 30 thousand- dollars would be appropriate. just. to 19 get the bare bedrock monitoring equipment :Ln- p-Lace,. and. 20 that woule be gene rous. I am sure the@y have something going. 21 1 think at this time to ask for,a cather-ized adult 22 cardiac clinic and to have particular EKG@int-erpretati.on. 23 I would, look computer assistance is something that a-t.with 24 a great deal of question. I would hope that there would be ce- Federal Reporters, Inc. 25 an indication that this will not be supported,. but. it- they, 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 new directions,, 4 but the old priorities as far as the Regional MedicaL 5 Program goes. If you can deduct that, which- is- a@ half-'mill loan 6 dollars, you still leave them with a, good boost f-o-r.,what-, 7 they have. 8 I don It think we should say- to.) the-za. wcr are7- going- 9 to look at how mature you are by whether- ar- not- yatL bui@ld@ 10 that. I would first build it., and then after r b@d@@ it-, 11 say I have suddenly become mature and I am. not going,- to.-, d@o@-.- 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 millioa dollars of7 their- request-. 15 goes to support basically to support pod atr-la, respiratory:. 16 care unit and the rest to refurbish a. heart station-. i:n a 17 hospital which should be done througJL o@r s@ces-,, 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 -year in spite of@ the 21 failure to recognize priorities and goals,, andso on, I- 22 think I share the confusion one might have witlr. the@ dual- 23 mission that made you go down there, Dr@.. White.. BtLt- I- do 24 have some concern -- perhaps -you- cou@ldi react toF ! i-t --how -do kce- Federal Reportefs, Inc. 25 you feel about that half a million dollars? Don"t, you, think 28i I we should put a strict no on it, and say well,._maybe a few 2 dollars for training, and the increment of $250,1000 over 3 the present.level of funding might be something t.hey-can 4 work with if we axe very strict about what theL guidelines. 5 are. 6 DR. WHITE: Well,, their present liave-L is s-even. fifty, 7 and we recommended a,million. Aad r tbLink-. thiw message. we-- 8 were trying to got to them, hopefu-. Ily. will gelt- ta@ theme , the- 9 bulk of that should be used to strengthen their @ action 10 planning functions, and the core staff and:personnal-required I I for that. If there is something left ovelr-- it. i&_ aliViOUSIYL 1 2 going to be insufficient for spending to@theF-extentl-that, 13 they are planning for either the pulmonary-or-theraor-onary. 14 care unit. They could then perhaps use 25, or- 30- thousand- 15 dollars to implement an educatioaal program,, but the-y@twould. 16 not have the resources required to@ begin: to., do,. what-. they. 17 are planning to do for the coron@. care., 18 DR. SCHERLIS: I would hope we. would, ga@ cm- 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 state I would have urged strongly, that. it'. be@ 22 supported because I think Dr. ELurke 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 ,ce- Federal Reporters, 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 2 funds. If they had asked a half million or million dollars 3 to take that state and set up a total coronary care 4 program in a stratified system I would be ail for 'it ancL 5 I would urge this group go in that direction. That I think-. 6 is a proper expenditure of RMP.funds, but not tolrefurbish- 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 little bit over a million dollars that is, 11 involved in that, and I heard Dr. White., r thought, a cntLpie@ 12 of times comment about his concerns about those two7programs 13 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 tims-as the@ 18 Regional Advisory Group can come back and jus-tify-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. WHITE: It's acceptable to me. I indicat-ed-in 24 advance that I would bend with the wind, and I so bend. ce- Federal Reporters, Inc. 25 VOICE: I would like clarification. The'three areas were pediatric pulmonary, coronary care,, -and what 2 was the third? 3 DR. MAYER: The renal program.. 4 Yes, Dr. Hinman. 5 DR. HINMAN: I would I ike, c.@lar-if icati:on- on-@ the 6 renal, what you were saying, Dr. White., Is: that, the-- RAG',, if-- 7 they could meld the two systems that have developed 8 independently into one that you feel it woul'd:be-@appropriate- 9 to consider the request before their next annt-versary,,or-- 10 would they have to put it off a year?; The: reason I' b@-i:ng@ thiE 11 up is part of the charity system has been,supported-by.- 12 some contracts from the kidney disease contral..program 13 which expire in the next several months,. and-Ithi@ would- @e. a.. 14 year before we could even. entertain-further- applications-- 15 from them, it would put theaL somewherel- between, nime, and.- 16 twelve months without any income to@ support, their kidney. 17 activities. 18 DR. WHITE: Can they get a new, contract?.@ 19 DR. HINMAN: Well, that Is another- ofpt,ion- that-- they, 20 could go. We would prefer -- the RIPS position would be 21 to try to work it into the grant mechanism rat-her than the 22 contract mechanism. That's why I brought ther question, up,, 23 if the answer is that you think it should waitfor 24 ,ce-Federal Reporters, Inc. another year for anniversary then vpe would have to go the 25 contract route to try to sai@e scme pieces- of i:t if-' it" seems@ worth salvaging. 2 DR. WHITE: Well, Dr. Hinman,, the evidence I' 3 have is that the Regional Advisory Grou@pL was. advised by 4 Dr. Sabatier that there were problems in7 this pXoje@. and-- 5 they chose not to regard the comments that he,made,,whi-ch. 6 I think is a reflection of their activity and interest... I'- 7 think it's critical that this be -re@wakened:., Secondly,, we have letters indicat,ing- that- there.- is-- 9 disagreement between scientists as to:the appropriate. way 10 of conducting this program. Therefore- r think-that-it- 11 requires a strong local review before it can- bar implemented.. 12 DR. HINMAN: Fine. 13 DR. RAYER: Ail right,, do, we@ have@ a c:.Lear@ 14 understanding of the motion? 15 What we are saying is recommending support,- of,' 16 million dollars for two -years consecutively-,, one million-. 17 each, with the clear indication that those d(YUArs@ should- 18 not be programmed into such unit deveiopment.as-re-pre.sent-ed@ 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. TOOblEY: I will second it.- 23 DR. MAYER: All right, any- further@discussiont 24 All those in favor say "aye.it -ce-Fedeial Repoiters, Inc. 25 (Chorus of "ayes.fl") opposed?- 2 (-No response.) Let us plan then on 8:30 in the morning. We will 3 4 be in executive session at 8:30 in the morning I wo-uld 5 assume probably for about an hour for staff this, is 6 an approximation. 7 We will in the morning tben@ start in witbL Weste@rn, 8 New York. we may have to slip to Wtropolitan, D. C. before 9 Florida because with Dr. Lewis Is 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 vould be to@ go 12 through them sequentially with that one exception. 13 (Whereupon, at 6:00 p.m."t the meeting recessed,, to, 14 reconvene at 8:30 a.m. the followiig day.) 15 16 17 18 19 20 21 22 23 24 Ace -Federal Reporters, Inc. 25