I i i-i ii 11 1 !III !I 1, i 1 I!l i llii !!! i'! i i iiii .11 z!@ 'I 11 I * ii 11 @ ' Iiiiiiiiii@l"Ol i 131 (II* VUL. 11 00 Transcript of Proceedings DEPARTMENT OF ]-IEALTH, EDUCATIONG AND WELFARE ACE FEDERAL REPORTERS, INC. Official Reporters 415 Second Street, N.E. Was"-,ington, D. C. 20002 Telephone: (Code 202) 547-C222 NATIO@l-%'!IDE COVERAGE DEPARTMENT OF HEALTli, EDUCATION AND IVELFARE i2 3 REGIONAL MEDICAL PROGRAM SERVICE 4 REVIEW COMMITTEE 5 6 7 8 9 10 Conference Room E, parklawn Building, 12 aryland Rockville, M Thursday, January 13, 197.' The meeting wts reconvened at 9:50 a. m., 14 Dr. William Mayer presiding 15 16 17 19 20 21 22 23 24 ,ce -eral Repoitefs, Inc. 25 2 C 0 N T E N T S 2 page 3 Consideration of applications: 4 Western New York 3 5 Florida 44 6 Metropolitan D. C. 68 7 Susquehanna Valley 128 8 Intermountain 144 9 Alabama 169 10 New Jersey 174 Northiands 186 12 13 14 15 161 17 18 19 20 21 22 23 24 :e - Fede ra I Repofters, Inc. 25 PF WESTERN XEW YORK m a a a P R 0 C E E D I N G S - - - - - - - - - - - 2 DR. MAYER: I think we better begin. We do have 3 a major task ahead of us before we finish the day. 4 And to prove that old RMP review members never die, 5 they just keeping coming back from Omaha Henry. 6 DR. LEMON: That's the only advantage I know living 7 in Omaha, you are a thousand miles closer to anywhere you 8 want to be. 9 1 am st-bstituting here for Dr. Spellman, very 10 inadequately. He was the chairman of our site visit team 11 which wa- composed of ivirs. Mars Of COUDCil; Myself; 121 Dr. Rebert Toomey, Director of the Greenville Hospital System who added a great deal to our capability, very perceptive; 14 ahl Dr. Silverbia-tt, coorL.',-nator of the Arkansas program, 15 who also was very helpful indeed. -And I think in the course 16 of the day and a half that we were at the headquarters of 17 Western New York-- 13 DR. MAYER: Henry, before we go on I just ought to 19 Perry has left the rbally indicate for the record that Dr. 20 room. Excuse me. 21 DR. LEMON: In the course of the day and a half 22 we interviewed a total of 45 individuals more than this 23 really, but there are 45 listed on the summary. 24 Now the general b@kground, I would like to ce I Reporters, Inc. 25 say something -- one of the.difficulties we had at this site 4 visit, the site visit was.structured probably improperly. 2 They misgauged our needs, and we had great difficulties the 3 first day in really finding out'what the health needs of 4 Buffalo and the seven counties of New York,,IVestern New York 5 and Pennsylvania that comprise this area. And then the 6 second day when we began talkidg with the county health 7 commissioners we got a very clear picture from them, and it 8 is a very complex situation, and I think this is reflected in 9 the history of grant applications from this area. 10 ophisticatio@i .They have been characterized by extreme s 11 and conce.-L@ration on things like renal disease and cancer 12 of the -,kin, rather small facets of a very large health care problem that they have, 14 Tjie Stati-, Univer@ - ty of New York at Buffalo is one 15 of the strengths there, But I note that in the American 16 Federation for Clinical Research help wanted summary 17 'there are more vacant divisional positions at the State '8 University of New York ac Buffalo, every department is looking 19 fol divisional heads. 20 There is a very strong department there in community 21 medicine headed by -- social and preventative medicine -- 22 headed by Dr. Edward Merror. It is very well financed, and 23 it has been a department of great strength; and Dr. Saitz, 24 who has been chairman of the 'program committee for the RNIP ce I Reporters, Inc. 25 in Western New York for'the last two years has been a key I figure in the operations of this program, and I think this is 2 one of the great strengths in this area. It is probably 3 one of the strongest departments in that medical school. t 4 of course, there is-the Roswell Park Memorial Institute which is an outstanding cancer center and they 5 6 have been extremely hard pressed financially during the last 7 few years, and I think this is ref lected in some of the 8 special types of project applications which have surfaced in 9 this area. 10 Now there are betwee'n 90 and 100 thousand under- 11 served core minority groups, chiefly black. The population 12 of Buffalo is 22 percent black at the present time. And 13 one of the interesting manifestations is that most of the 14 large hospital ;services are very close to or on the edge of 15 this core area. And a number of these hospitals -- most of 16 these hospitals have really no relationship to the care 17 of the urban core community, and there is a great deal 18 of antagonism, has been in the past, between the central 19 community and several segments of the hospital community. 20 This was not helped by the fact that in,1969 the 21 Western New York Regional Medical Program did deve op an 22 application which got up here to Washington in trial form for lth center to begin to make some progress in 23 a community hea 24 health services for this minority group, and they did enlist ,ce -eat Reporters, Inc. 25 the cooperation -- there are about 17 or 18 physicians, mostly 6 black, who work in this community, and they had a number of meetings under Dr. Ing4li's direction, and this got up here 2 3 and it received some kind of pocket veto. We don't know 4 what went on. It never did surface as a formai application, 5 but the Western New York Regional Medical Program lost 6 credibility with the black community. 7 And I think this explains one of the problems that 8 we saw, and it has been commented on by previous site 9 visitors, the lack of minority representation on the Regional 10 Advisory Group, on the core staff; and this ws brought out 11 rather frankly in our visits, that they have had problems in 12 getting cooperation from a number of well identified leaders 13 in the underserved group in their administrative activities. 14 Another thing which Mrs. Mars was particularly 15 concerned about, and some of us, was. that the Regional Medical 16 Program really doesn't get all the credit that is due it .17 for the many., many activities that do not even appear in 18 the application here which have gone on under Dr. Ingaills ver3. 19 able direction because it's identified as the Health 20 organization of Western New York. And HOWNY has been the 21 umbrella under which they have operated and to which the 22 physicians and the county medical societies have gotten 23 used to using, so that HOIVNY gets credit where credit is due, 24 and Regional Medical Programs do not. De -fat Reporters, Inc. 25 Now this was essential in the initial planning 7 phases, but we had considerable question that this had 2 anything except historical significance at the present time. 3 In addition to the hospit al care activities being 4 fragmented in the past and not serving many of the Group has een very 5 critical core areas the Regional Advisory 6 heavily provider oriented, chiefly by physicians; and while th s 7 is a very dedicated Regional Advisory Group, has some very 8 able, hard.working physicians, and they participate in every 9 phase of planning, eviuation, and supervision of projects 10 together, even some of the members go,on site visits, it is 11 pretty limited in its outlook still, and this is one of the 12 things we think has to be improved. 13 There are some Very grave elements of instability. 14 in the first place, Dr. Saltz has had the key position 15 on the program committee, chairman of the program committee, 16 which is a very powerful filter for all projects. All decisions 17 'are made by the program committee, and they have been very 18 able decisions. He feels that it's a position that he has 19 had this power too long, feels it should be turned over, so 20 he is resigning. And then Dr. Ingall laid his resignation 21 on the table of R@IP as of October Ist. It has not been 22 accepted yet, and he has indicated he felt that we got 23 the impression that he will stay on until somebody can take 24 over the reins. He will have been with the program for five :e I Reportets, Inc. 25 years this spring. But he is a surgeon. There is a lid on 8 I all ceilings, they are ke,pt at the level of the other state 2 institutions, the RMP, and with his children coming of 3 college age he said he just can't afford any longer to take 4 this on. He would like to stay with it, bVt it's an 5 economic disaster as far as he is concerned. 6 I bring these out so that when we go to I will 7 try to just excerpt portions of this site visit -- you will 8 have a little better appreciation of some of the problems. 9 Now the., have had a difficult time, as you can 10 imagine, in turning arounG from categorical, and really 11 highly si,--cialized categorical interests, to the new guideline; 12 And thf,-y -ha,! a conference in September, and they have done, I think, on paper a reasonably good job of reorienting their 14 ideas. And as I have indicated already, they have not been 15 unaware of the medical needs. 16 Dr. Ingalls actually after hours carries on a 117 small surgical practice in the black community. He is on a '8 first name basis with the physicians there. He is very 19 conversant with the problems. 20 But they have had problems in getting the medical 21 community reoriented. So they have identified -- turn to 22 part 6 here of the site visit report -- they have identified 23 goals, one, the promotion of preventive medical services, 24 the development of improved 'primary care services, and to ,ce- ederal Reportets, Inc. 25 integrate rehabilitation services into the continuem of 9 ts of objectives medical services. Then they have two se 2 and these relate quite definitely, and they are very articulate 3 about these on page 7. I won't read.over all of these.' These 4 are the fixed objectives. 5 'But one of the things that concerned us when we 6 came to the hard problem of which programs you are going o 7 fund and which you are going to have to delay when there 8 isn't enough money, they have floating objectives, and we .9 spent some time with the se floating objectives. They were .10 frank about them; but these relate to political considerations, 11 feasibility, and a variety of things which are not down on 12 paper, and we felt this was a matter of some concern to 13 US. 14 possibly more concern -- and this is stated on page 15 9 here these objectives that they formulated in this 16 September, 171 workshop as combined with these floating 17 I should have said priorities. Now this takes into account 18 the availability of leadership, the reliability of the 19 applicant, the local political climate, the impact of the 20 project on local vested interests. And we must realize here 21 that in New York you have a special problem. There are such 22 layers of institutionalization on the whole medical care 23 picture because the state has been interested in public and 24 has had very real concerns iD public health for years ,Ce ,al Reporters, Inc. 25 preceding R@-IP. The medical community is pretty well io I entrenched. It has been going a long time. 2 And so there are a lot of these subjective and 3 intuitive factors, and we felt that these were probably 4 used a lot by the Regional Advisory Group,in their decisions, 5 and probably in some cases were necessary ingredients. But 6 they did provide some disturbance to us in terms of their 7 proposal for use of a developmental component which was 8 really quite unstructured administratively. 9 And then 'you will notice in their grant application 10 on the sixth and seventh years, I believe, they are asking 11 for something like $250,000,$60,000 of what amounts to 12 additional development component. 13 And this relates $to another interesting feature. 14 This region does not have a large backlog of approved but 15 unfunded grants. They have probably 15 to 20 projects 16 that axe being formulated. But because of the very tight 17 way in which the Regional Advisorv Group and its program commit 18 run this, really they sort of take along each project 19 t-hey think is capable of being carried out and they get that 20 funded. But they don't have a list of appXoved unfunded 21 projects, so you can't really evaluate in terms of at least 22 the paper what the future direction might be in terms of 23 approvable programs or projects. 24 Now I think they have made very real accomplishment, :e-Fedetal Reporters, Inc. 25 and I'don't in any way wish to deny that this is a very I Valuable resource. And I think one of the things we would like 2 to bring out, that IVestern New York could provide leadership 3 for central New York and other areas in Pennsylvania, other 4 areas with rural problems, because they have managed really 5 initially to approach the rural health problem somewhat more 6 capably perhaps than some of the other areas, and they have 7 developed a very good model in their community health 8 information profile system which they are applying county to 9 county, and this has again worked. It's done under the 10 direction of the Department of Social and Community Medicine 11 by Dr. Ed Merror. 12 The outstanding new thing which has developed and 13' which will be a very significant factor is the Lal,,e area 14 health-education center in Erie, Pennsylvania, where they 15 have pulled together five community colleges, a number of 16 hospitals totalling 2406 beds, a variety of allied health 17 training programs, and the V.A. hospital there is financing 18 thisto the tune of $40,000 for the first year for administrative 19 help, and this is a real going planning concern that is going 20 to be an area health education center, probably one of the 21 first in the country. And I think we have to recognize 22 that Dr. Roth from Erie, Pa. has Probably been a pretty big 23 catalytic agent in this. And this has required very little 24 RMP money, but the outreach thro.ugh the State University at ce*fat Reporters, Inc. 25 Buffalo and the fact that there was a good core operation, 12 I although understaffed but that had input into all the 2 medical care activities of the region, this has certaini y 3 gotten off the ground a lot faster. 4 Another interesting thing is there is more and more voluntary participation by various physicians, allied 5 6 health professionals in the core activities. They'estimate 7 that as of last year 40 percent of total R@fP activities were 8 funded by voluntary contributions from the outside. I think 9 this is a good example of their very real success of being 10 able to act as a catalytic agent. 11 How they have this telephone lecture network which 12 has reached now over 30,000 allied health professionals 13 and physicians. We saw that. It has been very useful as a 'It,-is used 14 tie in to some 50, 60 community hospitals..;, . 15 probably more valuably, I think, by the smaller community 16 hospitals, particularly for allied health continuing 17 education than by physicians. But this is a very valuable 18 resource, and it is going to be one of the things that will 19 be continued. 20 Their evaluation has not been as strong as it should 21 be. It is headed by a very capable girl. We feel definitely 22 she needs more help. And I think their evaluation system ,23 is improvin- rapidly, and it feeds directly back to RAG 24 and is participating in their evaluation activities. As a Ce- Federal Reporters, Inc. 25 matter of fact, they cut off one of their projects a year in I advance because they felt it was not being productive. 2 They have given a lot.of help to the CHP agencies, 3 eleven, and the CHP and the OEO -- there is a $700,000 4 OEO grant to help in the care'of the urban poor which was 5 helped very materially by Dr. Ingalls and his group. 6 We come to page 12 here, this documents this -a 7 little more in terms of what I said, this i969 project 8 that they developed which didn't catch fire here in Washington 9 for some reason. And I just cite this to emphasize that 10 they have been aware of their responsibilities. 11 They have also carried out career ladder training 12 for innercity girls. This has been assisted by their core 13 staff. And they have been instrumental in getting the 0 14 innercity hospitals to begin to look at the community adjacent 15 to them as we will bring out. 16 It's emphasized, however, they do have Mrs. Mary 17 Northingto'n, at the bottom of pa-e 12 here, a new member 18 of the RAG. She'had worked as a research technologist, I 1'9 believe, for years. This is part of the incredible medical 20 background here, that they can get people to serve on their ..21 RAG who are very familiar with sophisticated medicine and. 22 who worked in research programs at Roswell Park. But they 23 haven't fully utilized these people, as was apparent from 2 4Mrs. Northington's testimony. They need certainly to expand @,al Repotters, Inc. 2 5their RAG. 14 Now we felt that Dr. Ingalls had done a very good 2 job. We don't feel that Dr. Ingalls is the worid's best 3 administrator. And I would just like to cite from this 4 page in your summary. This gives a very good picture 5 of the way their core staff operates. You notice there are 6 no clearcut lines of relationship. Everybody is doing his job 7 and Ingalls has got his finger in every pie, and it is 8 incredible that they submitted this, because this is a very 9 frank statement in their organizational chart. Vie couldn't 10 see that it was nearly as well organized as it might be. 11 Ingalls has to have a deputy coordinator if he is 12 going to do more. This is getting so complex. They need 13 to have additional staff and evaluation to help Miss Helberg, 14 they need to have more liaison people for their innercity 15 programs, and they need to have -- they just have one man 16 now trying to serve eight rural counties, and it just can't 17 be done in that area. So that these are some of their real 18 needs. 19 The Regional Advisory Group, to come back to 20 them, the preponderance of physicians, 20 out of 3i members 21 there are no representatives of labor unions, teachers 22 associations,, no hospital representatives, although they 23 have an excellent hospital network there, much better than 24 many other places. And as a matter of fact, we got a strong 6ce- Federal Reporters, Inc. 25 sense of noncooperation from the testimony of the local head I of their hospital association. I don't think this reflects 2 the attitude of individual hospitals. 3 The Regional Advisory Group does not have a 4 functioning executive committee. It's extraordinary. They 5 operate as an executive group, meeting monthly. They make 6 their decisions. The program committee meets twice a -year to (e 7 cide which programs will be funded, which will be cut off, 8 which obviously is not often enough for an active committee. 9 Proposals are disseminated among over 300 people 10 because each county has its own county advisory.group, so 11 that any proposal goes to this 300 group, and it's obvious 12 thet the rural counties don't feel they are part of the 13 show, that the urban RAG is running things, and it really is. 14 Furthermore the RAG -- there's no provision for 15 turnover. Some of these people have been around six, seven 16 years, and we were very critical of this. 17 We were also critical of the grantee organization, 18 and I don't know what RMP can do about it, but there's a 19 58'percent indirect cost charge for on campus activities and 20 48.6 for off campus activities. So really the R@IP dollars, 21 for every dollar that you are putting into an RMP program 22 there another 50 to 60 cents is going, siphoned off to 23 Hoalth Research, Inc., which is the grbLnts obtainin- arm 24 for all thestate agencies in New York like Roswell Park and Cele'll Repoiters, Inc. 25 the various public health research institutes, and so forth. 16 I And I think this together with the fact that.they 2 are tied in with an antequated, absolutely antequated salary 3 basis, which has provented.recruiting people into this, this 4 is going to be more and more of a handicap; 5 Participation -- I have noted the lack of hospital 6 and institutional involvement. Butthis is improving because 7 the Meyer Hospital and two of the sections of this current 8 application deal with assiStiDg the Department of Medicine 9 at the State University, at the Meyer Hospital, to develop 10 a continuing care program with some continuity which 11 would apply to the innercit,y underserved group. 12 ti,,d then the other outreach is a family practice program, which was ine of the e arly ones to get going at the 14 Deaconness Hospitul, one of the first in the country, which 15 is quite successful, and it is now serving -- this is also 16 within the black community now, it is providing major service 17 to the black community, and it is growing very fast. We felt, howe ver, the amount of money they wanted 19 to aid in this was possibly a bit excessive since this is 20 70 percent paying practice of medicine. 21 Local planning -- the county rural health for the 0 22 ambulatory care proposal which is sort of a mobile health 23 education unit, it's a very valid concept, it's backed by all 24 0 of the physicians in this one county, and has active' -e Federal Reporters, Inc. 25 participation from allied health. It's a very viable idea, I and we think that it will be an answer, at least one answer 2 towards getting closer to the interface of the health 3 care at the rural end of the scheme. 4 'It wasn't our charge, of course, to look into 5 projects, but I must say in terms of the million and a half 6 dollars that were appropriated for respiratory care the 7 testimony of Dr. Vance was kind of disastrous. He didn't 8 even have letters of approval on exters ion of this program 9 into the various rural hospitals for the next hundred 10 thousand next two or three -years. And we felt that obviously 11 not all of the appropriated money had been spent, and we 12 were very leary about any further allocation of funds. As 13 you will note in our recommendations, we wanted to turn off 14 the respiratory care program within 18 months. 15 The management, on pa-e 16 -- as I have indicated, 16 we feel that the project surveillance has been good, but 17 they need to have a better management structure, and,this, 18 would be aided by a deputy coordinator, and assistant 19 eV&Iuator, and also having field people to cover not -- a 20 least two counties, two or three counties, and these will be 21 in our recommendations. 22 I think that gives the general picture here. The 23 details are pretty well spelled out in this very good 24 summary'that Mr. Kline developed. And we think there is @ce lea I Repofters, Inc. 25 considerable short term pay-off with continued activity in thin I area, 2 In the first.place, the Alleghany County mobile. 3 health unit is a pattern that can be applied to other counties, 4 and it has the cooperation of the rural physicians. 5 Another intoIresting feature is that in another 6 -year they will have physicians that are trained in the.family 7 practice program in the Deaconness Hospital who have signed up 8 to go out to the rural communities to continue family 9 practice. So they are beginning to make a little headway into 10 tho-deficit of physicians in their rural area. .11 The Lake area educational project should certainly 12 get off the ground in the near fugure, and this will bring 13 in a variety of colloges,which are resources that have not 14 gotten involved, but which are very interested in getting 15 more involved in allied health Itraining. 1 6 one of the interesting facets here is that Dr. Perry 17 has never been a member of their RAG group there'and has 18 always been in a peripheral position, although he has been 19 extremely influential in developing the concepts of allied 20 health training and in the Lake area educational concept 21 in Erie County. He is certainly one that we were very, very 22 strong in our recommendations that they are neglecting a very 23 valuable resource by not having more allied health people 24 on thei r RAG. -*,,I Reportefs, Inc. 25 Now the recommendations. They are asking for the i9 1 05 level, coming to page 22, a total of $1,419,000 for the -year. And we made specific deletions on this. We 2 fifth 3 cut back the respiratory disease project by $50,000 for the 4 first -year. 5 We-felt that the comprehensive family health project 6 that is the training program for family practitioners which 7 is being run largely as a successful private practice 8 residency program at the Deaconness Hospital in the first 9 year would not need all of the funding that they had 10 requested, and we felt this should be site visited because 11 it is an important program, but we want to know, I think, how 12 the money which we are putting in, how this is going to be 1-3 utilized. 14 We also felt that this region probably shouid.not 15 have a developmental component until.their Regional Advisory 16 Group has been reorganized and until there is a better 17 characterization of priorities and how they are going to 18 utilize their developmental component. At the present time 19 their broad strategy is to divide this developmental 20 component half and half between the urban and rural communities 21 and to put it out in $5,000 contracts here and there. lVeil, 22 this may be a very good mechanism, and I am sure would have 23 some impact, but we felt that they were still pretty much 24 project oriented, until we could see more evidence of ce-Federal Reportets, Inc. 25 program development we should wait. zu We felt that the mobile health unit which is 2 going to cost $47,000, that R@IP should not be in the position- 3 of putting the whole money down for a piece of equpment, 4 that there should be matching funds. So we are OD Y 5 recommending 50 percent funding Of this. So we deleted 6 a total of $284,000 there from the grant, which would bring 7 down the recommended level to close to what it is now, 8 $19 1360000. 9 But in the light that we feel their core staff 10 needs enlargement by at least six members and this is 11 recommendation 4 -- dep-'.-y coordinator, an assistant or 121the preqent evaluator, two additional members to work 'with the county committees as liaison, and two specialists in health 14 aat+ers in innercity and r,,al health -- this might put back 15 somewhere around 80 or 90 thousand dollars. And this is 16 how we got at this figure, $1,219,000 for the first year, 17 and then I think something on the. order of ten percent -8 increments for the subsequent two years. 19 We felt that the respiratory disease project should 20 be cut back sharply. 21 And recommendation number 6, we felt there is a 22 real need for the salaries of the staff members to be increase 23 to levels consistent with people doing comparable jobs in 24 other RMP's., Now here we are up against a problem with the Ac ral Reportets, Inc. 25 Wage and Price Board. I Those were our principal recommendations. 2 The expansion of the minority groups representation, 3 consumer representation, hospital representation on the RAG. 4 And we felt that the coordinator should be congratulated on 5 doing an excellent job working 12l 18 hours a day many days. 6 He has tried to carry :oo much of this on his own shoulders. 7 We felt that the leadership role in the creation 8 of the Lal,,e area health education concept in Erie is a tremond(L 9 forward step, and the fact that they are profiling the 10 health needs of all of the county systematically with t ir 11 Chip pror-am, very gOOL. 12 We think that their telephone network information 1. dissemination their regionaiization needs to be improved 14 further, but with their t6 Pphone net they have,got all the 15 tools here. 16 So we fcel strongly that they are ready for 17 triennial support. But I think we have to recognize that 18 these two major elements of instability -- we don't know 19 wh is going to be the new director of the program committee 20 or chairman of the program committee -- this is a position 21 appointed by RAG -- and the 20sitiOn of Dr. Ingalls here 22 is tenuous. But I do want to emphasize he gave us the at 23 least he gave me the feeling that he would stay until a 24 replacement could be 'found. kce*,al Reportefs, Inc. 25 DR. MAYER: Thank.you very much, Henry. Comments of staff before we go on? Any additional 2 comments?- 3 All right, questions? Jerry. 4 DR. BESSON: I am not sure, Henry, what your 5 recommendation was for the diminution in support for the 6 chronic respiratory disease prograxa. It is requesting 7 93,000 and 17,000. 8 DR. LEMON: Weil, this has been a large project 9 which has concerned itself largely with training of 10 respiratory care personnel in some of the innercity hospitals, 11 and their projection w they felt it was really a 12 different project, but we didn't -- to move this out into I'l the community hospitals. But they nad Dot taken any steps to d @or this in the community hospitals 14 really det-3rmine -,,he nee 15 or the cooperation. And we recommended here on number 3, this 16 is page 22, the finding periodfor March ist, 172 to 17 February 28, 173 not exceed $60,000, and that this really be 18 in the phase of tapering down their present trainii,g activities 19 ar' evaluating what they have doni. We felt it was very 20 important to get maximum evaluation out of this for the 21 benefit of other R@IP's to sce what they have really ished. And not more than $32,000 for the 22 accompi subsequent 23 -ye ar . 24 So instead of putting in some 600 or 700 thousand .eO,,i Reportets, Inc. 25 dollars they wanted over the next triennium we recommended I only approximately $94,000 over the next two years. 2 -We didn't really want to penalize them too much 3 because we felt -- we didn't have time to go into all facets 4 of this., but it was apparent that Dr. Vance was not well 5 prepared to document his achievements or to indicate the 6 directions in which they were going to go in the next triennium 7 DR, BESSON: The other question I have has to do witi 8, the function of the research foundation and their charges. 9 What are included in those overhead costs that they pays 10 DR. LEMON: Bert, I may need your help in this. II But they process the cl 4.rges. The Western New Yor4 RITP 12 pays its own rent, does it not? MR. KLINE: As I understood what they described, 14 they provide recrLitiDg se-vices, attempt to iocate personnel, .15 they maintain ail records of expenditures, provide these 16 on a periodic basis. By and large I think they serve as a 17 resource to Western New York, and they didn't get into a great 18 deal of detail. rut as I recall the conversation, the R@IP 19 st-ff felt they were getting a considerable number of 20 services. 21 DR. LEMON: They get consultant services, too. 22 They get a wide variety of health consulting services for 23 free from the other state agencies andbureaus through this. 24 And they came back several times -- the associate dean, I *I Reporters, Inc. 25 believe', testified -- or was in Ingalls -- testified that they felt they were probably getting more for their money than 2 RMP was putting in. But we were in no position -- you know, 3 we weren't accountants we couldn't really get the dollar 4 value of this. 5 DR. BESSON: What is the customary charge that a 6 grantee organization makes for this kind of service? This 7 is not really overhead. It isn't covered in the usual 8 contract sense. 9 DR. LEMON: It is overhead because some of the grants 10 or contracts thut the state of New York accepts through the 11 Health Rt-search, Inc. "ive no overhead provision, or 8 or 10 12 or 20 percent; and the reason that they have to charge RMP this figure is to make up for these other low overheads 1 4 so they co-ne out -with an -,rerage somewhere on the order of 15 25 percent overhead for all of their research grants, 1 6 contracts and outside funds. 17 DR. BESSON: Of dourse) the aspect of your site 18 visit comment tha-'%-, somewhat astounded me when I read it, 19 tt.,t RMP is really bearing the br,.int of the ceilings on 20 overhead that thestate of New York charges for entirely 21 different programs, and thir kind of penalty makes me wonder 22 why you are chary about recommending a new grantee 23 organization. 24 DR. LEMON: I think this involves administrative ,elat Reporters, Inc. 25 decisions involving several,other RHIP grants. All we could do was to point out two things, that this seemed like a very 2 high overhead figure, which, of course, is magnified 3 in central New York and other areas in Now York; and secondly, 4 that operating as a part of Ilealth Research, Inc. they are 5 locked into the salary levels, but do have more flexibility 6 than if they were funded via the state. This was one of 7 the other reasons why Ileaith Research was developed, 8 because it provided more flexible utilization of funds 9 than the very rigid restrictions which the state-- 10 DR. MAYER: Henry, let me comment. I find it hard 11 to believe, knowing how the audit of overhead costs goes, 12 that they would accept RMP or anyone else carrying the load of someone else any more than Medi--are would accept a 14 hospitals indigeit care component as part of cost. You 15 know, costs are costs, and I assume, they are being prorated 16 on the cost relative to RNIP or any other group being 17 involved with that group as a group. 1 8 And I find that, you know, that last statement just 19 a.Praost impossible to believe. If it is going on that way, 20 that is they are absorbing some of the other costs of other 21 programs, then there is no question that it needs to be 22 reviewed in detail. I just find that hard to believe.. 23 DR. LEMON: I believe this came from the Vice 24 President of the State University of New York. 'elel Repofters, Inc. 25 MR. KLIL\'E:Yes, in direct questioning this was @rought out. 2 DR. MAYER: Well, then my suggestion would be that 3 that situation needs very strongly to be reviewed., 4 yes, Mrs. Silsb ee. 5 MRS. SILSBEE: Dr. Ingall is coming down to 6 talk about the possibility of moving his Regional Medical 7 Program to another grantee situation. He is 6xpioring it 8 and trying to move ahead. 9 DR6 BESSON: Would it make it any easier 10 administratively if we with fair play of turnabout put a 11 ceiling on the overher-i that the grantee-- 12 DR. MAYER: No, you don't have that right. MR. CIIAMBLISS: May I co.anent? 14 DR. MA"R: Yes Go ahead. 15 MR. CIIAIIBLISS: Let me just say, please for the 16 committee that the overhead rate, as you might know, is 17 not negotiated by the individual programs of HSHMA or the 18 individual prograns'of HEW. The overhead rates between 19 t@9 universities and their foundations, or what have you, 20 is negotiated by HEW. So once the rate is established and- 21 negotiated wherever our fUDds are placed in a given RMP 22 that grantee overhead negotiated rate will prevail, and 23 that is the case in this RMP. 24 ceel Reporters, Inc. No w to speak with,regard to the salary policies, 25 it has always been our policy in RIIPS that the salary policies of the grantee institution prevail. So whatever 2 salary polities are in the university system would 3 automatically apply to the RMP, 4 That may be the basis uponvhich Mrs. Silsbee makes 5 the point that this R@IP is contemplating moving out and 6 moving into a nonprofit corporation. This would give an 7 opportunity then for that nonprofit corporation to negotiate 8 its own rate and for a rest.ructuring of the salary levels. 9 DR. MAYER: Additional conl-nents? 10 Yes.. Lan. 11 DR. SCHERL.TS: Will you project as to whether or 12 not you think the present coordinator will remain, or were 13 -you in effect granting funds really not knowing where the 14 leadership will be derived as far as this area is concerned? 15 DR. LEMON: I can't say anything more than I think 16 that Dr. Ingalls is emotionally very involved in the 17 program. He has been the heart and soul of it for the last 18 five years. I think he plans to stay in the Buffalo area, 19 abd I think that who ther or not he is in the saddle that 20 perceptive people would continue to build on what he has 21 developed. 22 The other two stabilizing factors are that the 23 ROgional Advisory Group has some very dedicated people like 24 Dr. Felsen, who is a very capable practitioner from one ceol Repoitets, Inc. 25 of the counties, very knowledgeable. And you have to bear I in mind this RAG has been functioning pretty much as a team 2 for several years and workings, very closely with Ingalls. 3 The other thing is Ed Morror's Department of 4 Social and Community Mediciiie,.which has given extraordinarily 5 good leadership, is a stable factor. 6 DR. SCI-EERLIS: I recall making a site visit there, it 7 was a technical review, and one thing that impressed us was 8 their number of project.requests relating to what really 9 amounted to central laboratory support at the university. 10 And I note on page 7 of the yellow sheets that they now have 11 an immunofluorescence service and training, and a regional 12 coagulation laboratory that is to be supported through carry- 13 over and rebudgeting funds. 14 I was wondering if there still is that emphasis 15 on using the central laboratory supporting its functions for 16 the community. I think our technical review, as I recall 17 it, was not too favorable, if-I am not mistaken. 18 DR. LEMON: Right. I think I tried to indicate 19 'the@ were trying to phase this out, and this is definitely on 20 the way out. They realize the new direction, and the-y are 21 quite conscious of it. 22 DR. MAYER: John. 23 DR. KRAWLEWSKI: Ivas wondering if you would expand 24 a little bit on the salary problem, because we are giving ce I Reportefs, Inc. 25 them a fair amount of increase for core budget here to hire some 29 ten new people, or something like that, isn't it, and are 2 they going to be able to find these people, are they going 3 to be able to hire them under this schedule, or is there 4 a change imminent? 5 DR. LE-MON: I think i t was they had an'assistant 6 evaluator, didn't they, Burt, that they finally dropped 7 from their table of organization because they couldn't find one 8 under their present salary levels. 9 This is a very high cost area in terms of taxes and 10 living expenses. The ceiling present on salaries is, I am 11 sure, one of the reasons why the university medical school at 12 Buffalo is in want of so many division directors, And I 1.3 think Dr. Ingalls indicated he had great difficulty -- he 14 was looking for a replacement, had been looking for several 15 months, and there is no one in sight, 16 DR. KRAWLEI@BKI: How much is he getting paid? 17 DR. LEMON: Thirty thousand. 18 DR. KRAWLEWSKI: lYe are recommending about $250,000 19 inc@ease for core., is that correct? 20 DR. LEMON: No, about $80,000. Some of it could 21 probably be rebudgeted, but the two most expensive things 22 that -- Burt, you correct me, but the deputy coordinator and th:! 23 assistant to the-present evaluato:e"and then two additional 24@ members to work in liaison. But'the increased core would be LI Repofters, Inc. 251 somewhere on the order of 80, 85 thousand which we woLild I recommend. 2 But, of course, under.a triennial, as Iunderstand .3 it, this would be their option that they could make these 4 salary adjustments if it could be done within the framework 5 of the sponsoring institution. 6 DR. KRAWLEIVSKI: I guess I don't understand that 7 budget. 8 DR. MAYER: You need to go to the yellow sheet, 9 page 5, which is where John is and where I am., I have got 10 the same problem. 11 DR. LEMON: On the yellow sheet, page 5, okay. 12 DR. MAYER: Which, depending on your visual 13 acuity, it says in effect that their current budget for core 14 in the current fiscal -year -;Ls $343,903, and what is being 15 requested in the 05 -year is 587. That's the point I think 1 6 John is making. 17 DR. LEMON: I think we are looking at least the 18 figure we were working on was this is awarded three one 19 sev@nty-two twenty-eight seventy-one. That says 447 for core. 20 But what we were working on was the awarded for the 05 year. 21 DR. MAYER: I see. 22 DR. LEMON-. That's the 05 year, where they are 23 requesting 587 thousand for core. So, see, they have 24 already made an increase in their request for core to provide ,e I Reportefs, Inc. 25 some of the things that they need in terms of better Liaison with the rural counties. 2 The community continuing education network of 3 hospital -- that's their telephone network -- we didn't 4 touch that, $82,000. The items 3:and 3A for chronic respiratory 5 disease, we cut from 110 to 60 thousand for that year. They 6 have already phased out the fluorescence. The tumor 7 registry, there was some question about this. This supports 8 four secretaries at Roswell Park, and it.'s just a locali 9 based tumor registry, you,know. And in this day and age of 10 nationwide programs like the pass map, and so forth, I just 11 wondered, but we felt we would leave that in because this 12 is one of the things that ties these divergent elements 13 together, and it does cover the entire local region. And it's 14 obviously well directed, I think. It is going to provide 15 information. It is the only activity in cancer. 16 The model pro-ram for comprehensive family health, 17 that is the family practice program, 171 thousand, we cut 18 that back to 50,000 a -year for two years until it can be 19 site visited technically and until we see what the 20 potentialities are,., 21 DR. MAYI@CR: I think, Henry, the only question that 22 John is raising really relates to it would appear -- and I 23 still don't understand -- what we are recommending is 24 a $240,000 increase over their existing year as far as core cel*al Reporteis, Inc. 25 is concerned. And he is raising, I gather, the question in I light of the other comments -you made concerning recruitment, 2 salary levels, et cetera, whether that was feasible. 3 DR. LEMON: I think this is a big question. We 4 felt that their core staff was really much too small for 5 an area with as complex medical interests as this. Dr. 6 Ingalls, you see, has been trying to do all things, and it has 7 just become apparent he can't knit the hospitals together 8 into a better integrated program. 9 There is now one Lackawanna health clinic functionin 10 that was developed by a medical student, who is now its-direetor 11 in an area of 7,000 underserved people imprisoned in this 12 industrial cage of railroads and factories where they only 13 had two physicians, one of whom was 80 years of age two 14 years ago. 15 There are two other OEO health centers in the 16 process of formulation which will serve another 30,000 people. 17 'nded th ough OEO, and it is .There is a lot going on there-fu r 18 supported by the State University, that he is going to have 19 to try to keep tabs on. 20 So that whether he can find these people we don't 21 know. Obviously there are good people there who-are doing 2 2 a job which aren't represented on the RAG or on the core or 23 anywhere else. 24 DR. MAYER: Sister Ann'. ,ceoal Reporters, Inc. 25 SISTER ANN JOSEPHlh'E,: Dr. Lemon, do you think.that ail this I when for a while Dr. Ingall has been coordinating 2 effort himself and not letting anyone do it that under his 3 direction it would be possible for someone else to function 4 effectively and have satisfaction from his job? This is 5 always a problem. You knowt even if he brought in extra 6 people, because of his tendency to do it all himself they 7 might not stay. 8 DR, LEMON: I think he is interested in getting back 9 to surgery. lie is a board certified surgeon, and he 10 indicated he has been trying to keep his hand in doing some 11 after hoi,--s work in thL community hospitals, but he would 12 like to got back to his professional life. So I think he would gradually phase back into being a practicing surgeon. 14 I don't ha@,e any real -- E rt, what would you say -- I think 15 he was anxious to let go of this thing. 16 tiR. KLITIE: I don't know. I didn't come away with 17 'any.real strong feelings. I came away vague, as may be 18 reflected in the report. But I got the feeling th&t he would 0 19 not leave)certainiy until there was an adequate replacement. 20 And he seemed a little bit'vague as to whether or not 21 his resignation he has officially submitted was still in 22 effect. He made some indication that it was his hope 23 that through this he might get some assistance from the 24 cet,al Reporters, Inc. grantee organization. 25 And I also possibly might just indicate a little bit about what has happened in the interim period here. I 2 know that they are giving consideration to change of grantee, )r 3 trying to give consideration to this, because this would, I 4 think, ease Dr. Ingaills problems which are primarily salary 5 based, and also relieve his recruiting problems where he 6 recommended here six new people; if he were to get some 7 salary levels I think he would feel he would be able to attrac; 8 the kind of people he would like to have. 9 Then also they are working to expand the current 10 RAG membership from 33 to 55, which is consistent with the .11 kind of re that is suggested here. 12 These are just some additional thoughts. But I 13 really don't know the answer to the question posed, Dr. Lemon. 14 I came away very vague on this. 15 DR. MAYER: I think Sister Ann is suggesting that 16 even if you are able to change the grantee organization, 17 even 1'f -you are able to produce salary levels that are 18 recruitable, the question that is being raised is, you know, 19 maybe because of his concerns and lack of ability, or whatever 20 you want to call it, in administrative activity, that he 21 may not even be able to do that job with those restraints 22 removed. 23 Welcome, Robert. 24 DR. LEMON: I would like to say one other thinm. -cee'l Reporters, inc. 25 Dr. Saitz, who is a dentist, but who has really been I functioning as the deputy director for the last two years, 2 is chairman of the program committee with the power to appoint 3 his own ad hoc evaluation group, his own membership to 4 his committee, get any kind of technical advice he needs -- 5 very able health planner, very good know-how, very good 6 community relationships. And I think Dr. Saitz could step in 7 and keep much of the program going if any crisis arose. 8 DR. MAYER: Phil'. 9 DR. WHITE: Henry, on the one hand -you tell me 10 thalyou feel that this region is capable of managing its own 11 affairs presumabi y, because you are recommending a 12 triennial award, which to me suggests 'your consider ation 13 of their corporation is favorable. on the other than, you 14 make recommendations for specific dollar reductions of 15 specific projects. And subsequent to that we have these 16 conversations now on these various points. These two sets s 17 of discussions seem inconsitent,.paradoxical. I am 18 reluctant to accept your recommendation for a triennial 19 award in view of what subsequently 'you have said. 20 Can you clarify this for me! 21 DR. LEMON: Well, I think we felt we had misgivings 22 about specific phases of this program. I think we came 23 away quite aware that their awareness of the direction that 24 they have to go is very good. I think our problems revolve .ce0rat Reporters, Inc. 25 around the fact that these are not spelled out in detail in projects or programs that we can pinpoint. In other 2 words, there are many.good resources in this area, but as they 3 have indicated in their application on the seventh and 4 eighth years, the next two years, there is a large block 5 of money that they are asking for for program which is not 6 specifically allocated. 7 And as I indicated, we were not overly happy with .8 the large sum of money that had been spent in the respiratory 9 disease pro-ram. And obviously the site visit was partly 10 tuned to the report of the various projects. We had to 11 change the structure of the site visit. But we did not 12 get a feedback as to how much accomplishment had een 13 performed. 14 1 think with the present set-up they have a good, 15 hard working core group with lots of enthusiasm and 16 excellent leadership. And they have some things going on 17 I think that counterbalance some. of tile uncertainties, like 18 the Lake area educational program in Erie. But it 19 remains to be seen, -you know, how well they ca n bring in 20 the community college representations and all the power. 21 There's enormous power here for manpower training and for 22 development of better health programs. But the specifics hav(,- 23 not been spelled out that we could see. They are being 24 developed. I can't read the crystal ball any more than that. -e *I Reportets, Inc. 25 DR. MAYER: Jerry. 37 I DR. BESSON: Henry, I would like to return to this 2 matter, even though I know that there's some constraints 3 that Mr. Chambliss has indicated about that 60 percent rathole 4 that we are working with in this region. If I understand 5 correctly, the funding level that you are talking about, 6 1.13 million plus an extra 90,000 for core, 1.219, 60 percent 7 of that, 58 percent of that is never going to reach the 8 program? 9 DR. MAYER: That's a direct cost figure. 10 DR. LEMON: This is direct cost. 11 DR. BESSON: So that any way we slice it they will 12 get a 60 percent gain if that hole is plugged. 13 DR. SCHERLIS: No. Mr. Chairman, don't I interpret 14 our ground rules as not being concerned with overhead, that's 15 an outside negotiated item? 16 DR. IIAYER: Right. And I think we have suggested 17 that it is certainly one that needs to be looked at from the 18 evidence that has come back from the site visit, at least 19 somL evidence that I have just heard, and'I think it ought 20 to be pursued. But the figures that Henry is dealing with 21 are direct cost figures, Jerry. 22 DR. LEMON: I am tryingto justify the level. IkDOW 23 from previous discussions here this is where we have problems.. 24 And -you look at their present fundin- level, which is ,e eal Reportefs, Inc. 25 $1,100,000 -- is this correct? DR. MAYER: Yes. 2 DR. LE-MON: Somewhere in this bail part. We wanted tD 3 try and hit a funding level that provided some level for 4 growth of their activities. This is an area extraordinarily 5 rich in medical resources, and on the basis of ground work 6 they have done I think there will be considerable development 7 in the next two or three years. So we didn't feel that we 8 should really cut them back below their previous funding 9 level. And we did feel that we wanted to give every 10 inducement to have Dr. Ingai.Ls stay on in an active capacity, 11 and this consideration, if -- see, they do have -- under 12 Health Organization of Western New York they do have a 1-. potential funding agency right ther,.. This was the original 14 reason for thu creation of the Health organization of Western 15 New York, to have a funding agency for this program, and this 16 is where the allegiance of the physicians of Western New York, 17 is the Health organization of Western New York 18 So that if this could be taken out of the 19 acc--ie,.nic lid and put into an HMO, or something, where they 20 could pay some realistic safari es -- you know, -you have to 21 pay a little extra to live in Buffalo. This is the other 22 problem. They have probably got the world's worst climate. 23 It isn't Southern California. These are some of the realities 24 that people face in recruiting for Buffalo. ceeal Reporters, Inc. 25 DR. MAYER: Sister Ann. 39 SISTER ANN JOSEPIlIbTE: Dr. Lemon, did, they give any 2 indication of their plans for phasing out this tumor .3 registry from their projects? 4 DR. LEMON: They have been careful to put down on 5 paper with the other projects that they plan to phase this 6 out, and right now I cannot recall any specific statement to 7 this effect. Burt, will you correct me? I didn't hear 8 of any. 9 MR. KLINE: They initiated this for five years 10 and they have completed three years-- 11 DR. MAYER: Can't hear you, Burt. 12 MR. KLINE: I'm sorry. They initiated this as a 13 five year venture, they haveIcompleted three years, and their 14 plan is to fund the fourth and fifth years as originally 1 5 planned. 1 6 DR. MAYER: All right, other conuneDtS? 17 Would someone like to surface a recommendation? 18 DR. BRINDLEY: I move the approval of the funding 19 level as suggested by Dr. Lemon 20 MISS KERR: I second the motion. 21 DR. ?4AYER: All right, discussion? 22 The motion was that we approve the recommendation 23 of the site visit team. 24 MISS KERR: lVhich is not to include a developmental ,ce I Reporters, Inc. 25 component, but at the funding level by amounts that he 4U I indicated. 2 DR. MAYER: Ail right, discussion of the motion? 3 Philip. 4 DR. WHITE: I can't accept that recommendation. 5 1 just can't -- if -you tell me you need a crystal ball to be 6 sure what is going to happen in the future in this 7 region then this region is not ready to manage its own affairs 8 Further, as I understand the mechanism, Henry, if 9 you do indeed award them triennial status with whatever 10 amount of money is involved you can only recommend that 11 pulmonary diseases, or so on, be restricted. They indeed 12 then have the option of managing their own affairs. They 13 may be in danger next time around if they have gone against 14 your recommendations, but you can't actually control this. 15 Is this not correct? 16 DR. MAYER: That is correct. Let me suggest a 17 possible modification because I have the same kinds of 18 concerns simply because the coordinator is up in the air, 19 wh6re the fiscal agent is really going to be is up in the 20 air. Maybe what we need to do is throw in an amendment 21 which says that the allocations of funds for the 02, 03 year 22 of this triennium would be subject to review and site vis it 23 at the end of the 01 year, because 'by then my assumption is 24 by then Ingalls is going to opt one way or the other, they ,Ceoal Repofters, Inc. 25 are going to opt one way or the other by that time in terms -2 JL of where they are going to put their money, and whether they 2 can recruit, et cetera, et cetera. 3 M . KYTTLE: Dr. Mayer, if you move to accord 4 them triennial status on the-one hand which accredits them 5 with some decisionmaking authorities within the triennium, 6 and then on the other hand say that at the time of t heir 7 first anniversary application within the triennium you 8 want prerogatives over the allocations offunding decisions, 9 that's, I think, inconsistent. 10 DR. HESS: I wonder if maybe -the way to deal with th E 11 is the way we dealt with two regions yesterday, two -year 12 funding with site visit, giving them some money to plan 13 some basis for competence, but not going all the way as far as 1 4 triennial status is concerned. 1 5 DR-. @IAYER: All right, that's another option. 16 DR. KRAWLEIVSKI: A question of procedure. If we 17 gave them two year funding now could they come in for a 18 triennial application next year? 1 9 DR. NIAYER: Yes. 20 MISS KERR: That sounds like a good alternative. 21 DR. MAYER: Would someone care to suggest a 22 substitute motion? I know who the seconder was. Who made 23 the original motion? 24 DR. BRINDLEY: I did, and I will remove it and -0 Reporters, Inc. 25 Joe make his. DR. HESS: I move two year funding at the level recommended by the site visit team, Dot granting triennial 3 status, and with the provision of a site visit in o ne year 4 and their option to submit another triennial application at 5 that time. 6 DR. MAYER: All right. I assume there is a second 7 to that. 8 DR. WHITE,: I will second it. 9 DR. MAYER: All right, further discussion of that 10 substitute motion? 11 yes,, Jerry. 12 DR. DESSON: I have a question of operational format. 13 Once a region reaches triennial status they are then not 14 subject to review committee action, but only staff 15 anniversary review recommendation if there is request for an 16 increase of funds, is that correct? Does the review committe e 17 then have any funding jurisdiction? 18 MR$. KYTTLE: If the requested increase of funds 19 exc'eeds the'level of approval it may well exceed its level 20 of funding, but a region in a triennial statu s has the 21 latitude of movin- within its approved level. Staff 22 anniversary review panells action on an anniversary within a 23 triennium will come, and indeed we have some today to look 24 at, for basically information. But wealso have one today :e I Repofters, Inc. 25 that the SARP opted to send to the committee for action. But the anniversary within the triennium, unless it requests funds 2 that exceed the level approved,. or three or four other' 3 reasons not having to do with the question you asked, would 4 not necessarily come to this-committee for action. it 5 would come as information. 6 DR. BESSON: When does SARP take that option of 7 asking the review committee to go over the funding request 8 during a triennium? 9 DR. MAYER: Well, let me try, because I need to 10 see if I have got it. If it exceeds that level that is 11 approved by Council as @he funding level in that second year 121 of the triennium they would in all probability ask the review committee to look at it nuniuer one. 14 IJumber t-70, if i- their judgment there are some 15 issues that are there that are different than the basis 16 upon whicn the original triennium was granted and there are 17 significant changes, they might ask. And that's why 18 Northiands, for example, is coming back today. 19 DR. BESSON: But this is at the option of SARP? 20 DR. MAYER: Yes, that is correct. And that's 21 why I think that Phil is a little chary about triennial 22 status at this particular instance. 23 Ali right, further comments? 24 Henry, any comments? e Repor ters, Inc. 25 DR. LEMON: I just night say I think it is obvious I that this region is in a state of transition between project 2 programs, so I really wouldn't argue too strongly. As 3 long as they get a durable commitment that will permit them 4 to work on the Lake area heal'th education center and 5 support what they have ongoing in the rural and innercity 6 I would think that a two year commitment would give them 7 reasonable assurance. 8 DR. MAYER: All right. All those in favor of the. 9 motion say "aye." 10 (Chorus of "ayes.,,) 11 Opposed? 12 (No response.) 14 Henry, we thank -you. lie will now take about whatever is necessary to 15 register our'votes, to remind you that we are still doing 16 that. 17 We winnow move on to,the Florida project, with 18 Dr. Perry as the chief reviewer. 19 & The gentleman at the eni of the table now, as most 20 of -you know is Dr. Robert Carpenter, coordinator of Western 21 Pennsylvania R(3gional Medic&i Programs, who I didn't see 22 flinch perceptibly when I heard all that talk about Erie, so 23 I assume there is no conflict. 24 ceoal Repoftets, Inc. DR. CARPENTER: Just my poker face. Nice to be 25 back with you.' FLORIDA I 0 0 0 DR. PERRY: From my standpoint I am especially 2 happy to have Bob Carpenter here with us. I think Bob 3 will share with me how sorry we are that Ai Schmidt is not 4 with us for the primary review, for Al was the continuity, 5 having been at Florida RMP previously and returning to it. 6 We had quite a group on the review group. Three 7 from the review panel -- as Al said, wasn't sure they didn't 8 think he could handle it, or so damn many problems we better 9 have a group down there, but it was Al Schmidt, Ed Lewis and 10 myself from the review panel, Dr. Bland.Cannon from the 11 Council, and Dr. Bob Cr,,,oenter, as you have introduced, 12 head of the Western Pennsylvania R,@IP. DR. MAYER: With a crew like that I would have 14 been a little shak myself 15 DRi PERRY: Reinforced by a really excellent 16 group here from R@IPS, Jeanne Parks, Lymon Nostrand, and 17 Abe,Ringel. 18 We went to this region full of apprehension, and 19 Dr,'Lemon, who is here in the room, was certainly part of 20 that apprehension from the standpoint of his having. 21 participated in Florida and the reports that some of us 22 remember on Florida RMP. 23 The major difficulties, to review very quickly, as 24 you recall,, the problems as expressed and in all of our previous ,40 1 Reporters, Inc. 25 relationships with Florida, a ,,reat deal of dissent between I the RAG and the grantee agency, a lack of ao executive 2 committee', other subcommittee groups to do the 'ob; full i 3 of in-house conflicts, to a point where the dean of one of 41 the major medical programs was asking for .the removal of the 5 director of R@IP; a move toward secession of the north Florida 6 group area into its own R@AP; an imbalance of the areas 7 of Florida between the southern naturally headed by the 8 University of iliaxai group, the central University of Florida. 9 And thus we went to Florida. 10 Sometimes I think we can say miracles mrought by 11 people can happen. I think we did find some major changes 12 going on in Florida. And we were excited, first of all, by 13 a very excellent triennial application. 14 Okay. To some of us going down let's find the '15 reality OD what has been written, for we knew some of the 16 people that had gone to Florida recently and their capacity for 17 -writing. And so it was a test of reality to some of us 18 of how much we could find that was in truth fact in terms 19 of'what had been written. 20 The triennial application was extremely honest 21 in discussing the problems, but it was -lowing with the 22 changes that had taken place. It was not a duplication of 23 national policies, but it was a selection of those national 24 directions and recommendations that they felt might work ,e I*[ Reporters, Inc. 25 in Florida. And I think that distinction was extremely important to us as we looked at this. 2 iYhat are some of these changes then that have 3 taken place? The coordinator, Dr. Larimore, who had been 41 under all kinds of fire, has certainly taken a major leadership 5 role of coordination. I will discussion this in various 6 way, through selection of new staff, through a relationship 7 throughout the state, CHP relationships and you will see 8 this come out in many ways in this discussion. 9 Tho region has been successful in developing, 10 perhaps forcing in some ways, cooperative relationships with 11 the three medical schools in the region. The University 12 of Miami, University of Florida have been the major programs 13 in the past. But with the emergency of the University of 14 South Florida in Tampa, and as many of us know that program, 15 as iVs stren-henin- with sorm really. strong personnel that 16 is going to it, this one in the middle has seemed to be a 17 part of the major force of bringing three to talk together. 18 So there has been a drawing together of the entire state 1 9 of i'lorida into much'mo re of a region than had been seen at 20 any time before 21 The close working relationships with the V.A.. the 22 State Medical Association, Hospital Association, Nursin- 23 Association, these were very strong. 24 The workin- relatioiislii.p with CHP described and in e I Reporters, Inc. 25 action by the people appearing before us -- the chief of I Florida CHP serves as a member of the RAG and as chairman 2 of RIIP planning committee. The, RIIP director is on the CIIP 3 council working directly with the Health Services Committee. 4 Okay. This relationship is in action and is functioning 5 very, very well. 6 The core staff, though small, we found to be extreme- 7 ly effective. And to me one of the coups that has taken 8 place in this region is the attracting of Dr. Herman Hilleboe 9 to be head of their Planning Evaluation Committee. To some 10 of us from the state of New York, we recognize that 11 Dr. Larimore has brought down one of his former workers 12 and one of the people that he worked very close with in the 1 3 state of New York. Dr. Hilieboe was former co,,missioner of 14 health in the state. He hasn't gone to Tampa to retire. 15 He is intimately involved in the planning of this program 1 6 and the evaluation of this program. And again I will speak 17 to the way in which this committee has moved out in closing 18 up some projects that have been in operation for quite 19 so@e time, much needed things I think in many of the RMP'S. 20 Additional staff in terms of a member out of the 21 RMPS that many of us here around the table and certainly 22 around the room have worked with, Spiro McSossacits(?) is 23 joining the staff there in evaluation. He is looking forward 24 to working close with the big b6y, Dr. Hilieboe, that lie ,ce al Repottefs, Inc 25 knew in New York state also, and he will be a strength to the program. Sidney Froberg, the nurse coordina tor on the staff, 2 3 I found to be a very strong forcein the total project. 4 Their monitoring and their financial system has 5 been completely re-audited. The quarterly budget system that 6 was explained to us in detail for rebudgeting of unused funds 7 and the forces moving on that for efficiency and effective use 8 of money we were impressed with. 9 I think in looking at the goals I am not going 1 0 to take time, I know the amount of time -you spent on the 11 last one -- that I am going to go as quickly as I can in 12 relation to some of these areas. But the important thing in looking at the new goals, which for the first time they have 13 14 spelled out and are attempting to implement, the key word in 15 the statement of goals is not just one of these motherhood 16 kind of things. It starts out let's identify the gaps in our 17 'health delivery system rather than we are going to do the whole bit of health manpower and all, let's find the gaps 19 and let's move in this direction. 20 They have come up wit h good data resources for 21 planning to the RAG, and I am sure that John remembers some 22 of the problems in relation to that group. There has been 23 a broadening of membership. They are looking at taking 24 on other people into the RAG. As I mentioned previously, CHP le I Reporters, Inc. 25 etc. have been involved here. 50 The head of the RAG, the chairman of the RAG is Dr. 2 Kyle E. Moore, Dean Emeritus of social work at Florida 3 State. Haven't found a social worker involved in this role 4 in any other regions that I have worked with. He is not only 5 a politician, maybe he does a little role playing and all 6 with some of them, but he is proving that age has very little 7 to@ do with new ideas; and in this state in the way in which 8 they are moving ahead, I think he has been a strong part 9 of this. 10 Effective task forces have been set up, not only 11 the categorical ones, but in addition to the categorical ones 12 Council on Continuing Education, Committee on Health Services 13 for new directions and to look at some of the broader issues; 14 a new steering executive committee, and a very strong executive 15 committee, has just been put together. 16 Okay, examples of strength as I am going on on this, 17 the Planning and Evaluation Committee that Dr. Hille oe 18 is in charge of, began looking at ongoing projects, and 19 as a result some of the projects were terminated early and 20 others have been cut back. 21 1 would like to speak specifically to this, and I 22 think certainly Al Schmidt would have done this. At the 23 time of the previous site visit the "ruler of the house'' 24 at that time was in many ways the University of Florida at Reporters, Inc. 25 Gainesville with the strength and the powers that be in that situation. Some of the projects that were closed out and 2 that were reduced are those projects from the University 3 of Florida as the region has become strong through their 4 Planing Evaluation Committee-and through the total regional 5 approach of a state. 6 The.grantee agency, fiscal agent, has been changed 7 from the Florida Medical Foundation to the Florida R@IP 8 Programs Inc. 9 These kinds of changes that have taken place through 10 the direction, u@Ohn, of -- you know, of.a period of time, 11 to Al?e and to those of 'is who were there the first time 12 were extremely significant, we thought, in terms of what had gone before. 14 rontinuEtion of qupport. This has been built into ti, 15 evaLu ation approval of each new project. And listen at 16 this -- seven of the projects currently in the final year 17 of RLIP support will continue through non-R@iP support next 18 year. Seven projects. I was most impressed with that. 19 There is effective planning at the local level. 20 Eight district offices have been set up. I will talk-@ong 21 the weaknesses of something that I think can be added there. 22 The process of application, the decisionmaking 23 process and such, has been greatly strengthened in writing, 24 in all kinds of effective communication systems throughout 'ce0al Repoiters, Inc. 25 the state. I can mention son.e of the kinds of materials I Planning guides for applications, application materials, 2 staff review checklists you know, in addition to the 3 panels and such that we spoke of. 4 To give just a brief feel on the kinds of projects 5 that they have moved into this regional scope I will mention 6 just a few, but they do support their goals and priorities. 7 For the distribution of health care services in the region, 8 improving delivery; the children's cancer program has 9 succeeded in developing a regional network of four centers 10 in the areas of Miami, Tampa, Gainesville' and Jacksonville. 11 The cervical cytology nroject has also established a 12 network of six centers for'screening high risk wo,me@n for 1: cervical cancer, and these are in 'he target populations 14 of,Jacl,.sonvi.Lle, Ifiami and Tampa, where they will move 15 ahead into other areas in the following -year. 16 The health guides project was one of the exciting 17 projects we saw down there. This is a new type of health 18 worker that has bpen developed to improve the health care 19 services of the model in the neighborhood area of Tampa. 20 This is bringing the indigenous people into the area into 21 the process of moving into the home, finding where the 22 prcblems are, ge tting information of where you can get service 23 on that very level. We suggested a replication of this 24 in several other places. Iceis al Repoftets, Inc. 25 The extended campus concept project, involving 1 large numbers of nurses and allied health workers in 15 2 county hospitals utilizing resources of a community junior 3 college is also moving out in various ways. 4 There is a proposal. among their new projects in 5 the triennium, the region proposed developmental educational 6 program designed to educate the black community, physicians, 7 nurses, allied health personnel, regarding sickle cell 8 disease. The leadership will come from the black community 9 on this. 10 Not just in writing we saw that they- are indeed 11 in the process of planning a health care delivery system for 12 the poor, and this study is being conducted, will be 13 for the medically indigent target groups, and they have got 14 quite a few in Florida, including the aged, the migrant, 15 the rural poor, and the suburban poor. 16 I would mention finally among the projects project 17 'number 44, which is an assessment of health manpower 18 that will be done in their eight district offices for the 19 assessment of physician, nursing, allied health manpower, 20 which they are using as their assessment toward the 21 viability of area health education centers in each of those 22 areas. 23 In terms of the last area here that I want to 24 really hit here on some of the materials that that region @ce*,al Repotters, Inc. 25 has developed -- and I feel a lot of this could be used as a model other places these checklists for new operathnal 2 proposals, the staff review checklist, the summary of 3 cIo=ents and findings form, some of the things they have put 4 together there for information to prospective people that 5 are putting together grants. I think some of our projects 6 that are in such need of how to develop and where to go, 7 they have got some real strengths there going for them. 8 at they are doing For the weaknesses: granted th 9 a lot in the area of minorities, and such we found no 10 minority groups on the core staff, minimal representation on 11 RAG. There is some evidence of minority representation on 12 task force. 13 More important than anything, however -- this is 14 hot something they hid behind, they recognized the problem 15 and discussed it quite openly. 16 They also discussed the difficulty they have found 17 in implementing certain programs and projects because 18 many other state agencies have moved out in this area in 19 Florida to so implement. As an example, the Cuban population 20 in Miami has money coming out of its ears from all other 21 kinds of projects attempting to do something for the Cu an 22 population. 23 We have recommended, however, possibly the Tampa 24 health guides project is something they can move in here. ce*,al Reportefs, Inc. 25 They are looking for some leadership people in the I @ I minority groups to move with, for they have'involved in the 2 health guides program membersfrom particularly the black 3 community working in some of their training programs. They 4 have got one key person that has just arrived there, as the 5 dean of Allied Health,, Florida International, Dr. Van White, 6 who I had the privilege of bringing up from Louisiana 7 and training in my own place as my assistant dean, has just 8 -taken the deanship in allied health in Florida International, 9 where he he setting up programs for South America and for 10 the blacks in that area. The y aiready.knew him. I didn't 11 have to introduce him. They already knew him, and they are 12 planning to get him involved in the program. 13 These then are the major strengths of the program 14 as I saw it. 15 Before we go into any recommendation or I give any 16 recommendations on the funding I would like to ask Bob to 17 jump in here. 18 We do have a renal disease project to very briefly 19 discuss because Ed Lewis was with us, as he mentioned to 20 you. This project had not oni y his review while he was 21 there, it has been brought back with representatives already 22 from the Florida program meeting with the people on kidney heie 23 in the office. The recommendation is for a major cut 24 from over $660,000 in the project to $250,000. We can get :eoal Repofters, Inc. 25 into that later, Bob. 2 DR. CARPENTER: Thank you. I can't imagine what 3 1 could add to that fine description of the region-p- 4 DR. MAYER: Comma, but. 5 DR. CARPENTER: Beg your pardon? 6 DR. MAYER: Comma, but. 7 DR. CARPENTER: Yes. No, I am just going to 8 highlight some of the points that Warren brought out. 9 I wanted to clarify that we,did in fact the night 10 before the meeting go and purchase guns, one apiece, and 11 slipped them in our be-k pocket and went in, and I am .12 happy to report also that at the end of the site visit I sold my gun at a five dollar prof i 14 We founi, as Wa-ren said, much support, in 15 watching the interactions of people and hearing their detailet 16 descriptions of projects, much support for the very well 17 written application. 18 We were impressed, all of us, with the f act that 19 tr,)y had arrived at a very logical arrangement to link 20 CI[P and RHIP. They sim ly aske d the state CHP chairman to p 21 set the objectives for the 'Regional Medical Program through 22 an objectives committee, and this has been done. 23. The objectives are still somewhat broad, and they wil 24 have opportunities to refine. their thinking about what cel&i Repotters, Inc. 25 should be done and what can be done in Florida. But 57 I nevertheless they are well started in that direction. 2 The cast of characters is impressive. The staff 3 are active and intelligent and alert and excited about their 4 program. State health leaders visited us, The medical 5 society leadership was actively involved, and the universities 6 in Florida were becoming involved more evenly and I think in 7 a very effective way in the program. 8 All of us were impressed with the management, and I 9 think that such evaluation as has been accomplished has been 10 largely from the management people, because Dr. Hiileboe has 11 only recently joined t -3 program. They have been very 121 effective, and it was partly because of this and partly because of the great success in phasing out projects and 14 achievin- private support that we all came away with a feeiini 15 that you could trust these people with really a good bit 16 of money. 17 I was impressed that the subdivisions of the 18 'program, the area advis:)ry group, the subregional groups, 19 w( 7e led by physicians, and not cid retired physicians, and 20 not young physicians that couldn't have their practice 21 going well, but seasoned, a,tive physicians. The one from 22 Miami, for instance, was a past president of the Miami 23 County Medical Society. And each of the eight regions is 24 led in this way. ,e al Reporters, Inc. 25 Organized medicine is also very much involved I through the offices of Dr. Philip Hampton, and he holds the 2 grantee organization together-and has been, I think, iargeiy 3 responsible for puiiing the medical schools, the medical 41 society, and the other elements of the health care system 5 into some working order. And he is aided just magnificently 6 by a social worker who is now social scientist who is ieavin 7 actually he is not, he is a southern gentleman and a very 8 talented individual, and I want him for a,RAG chairman n 9 my region. He's really great. And the training in group 10 dynamics that he lived with ail those 'years is really,' you 11 know, just rightfor a RAG chairman. 12 Dr. Lamar Kravas at Gainesville has led the 13 medical school involvement in the program, and he did it 14 a little actively at the beginning; and I think until the 15 understanding about an appropriate-role for medical 16 educators in the regional program came along perhaps there 17 was some problem about that,. but in the end this tremendous 18 energy has been harnessed very well and has been working 19 very hard for the program, and the other schools have 20 followed that leadership from Gainesville. 21 1 think Warren mentioned also their willingness 22 to follow a good many federal initiates. As you see,'their 23 a-re& advisory groups, subregional groups, are to move into 24 the area of area health education centers and emergency ,e*1 Reporters, Inc. 2 5 medical service in the coming years. I The renal grant I think was a nice example of how 1 2 well things are working. We were faced with tatented'people. 3 They were hard working, knowledgeable, bright, and had been 4 successful in the past, just the kind of'health professional 5 that one would like to have serving a region. The 6 geographic distribution of the people talking about that 7 renal grant was exactly what a master planner might have 8 hoped for, and they really could work together. 9 But there ware some discussions, you know, where 10 things were not seen exactly the same right off the bat 11 by people from Gainesville and people from Tampa and people 12 from Miami, and in the site visit situation they very 13 quicl@,ly handled this, and each person's leadership role 14 became pretty evident. 15 So I think, as Warren sai.d, they need to realize 16 that there are other allied-health professions other than 17 nurses, and they do, and Warren.helped them.considerabi-y to 18 see the importance of that, and I think that they will 19 b3&oaden'their representation on planning committees. 20 They need a little bit better objectives, little morc 21 active evaluation of the kind-other than the fiscal 22 evaluation. 23 But all of those things are'under way, and it 24 was, as Warren said, all our impressions that this was a regici @ce0al Repotters, Inc. 25 that has the mechanism, has the leadership, and needs the money. 2 DR. MAYER: Before you go on to the discussion I 3 might make a couple of comments. I did have an opportunity 4 to talk to Mac Schmidt in Chicago on Monday and Tuesday, 5 and I would only indicate his real concern about not 6 being able to be here, and I know that that concern was real 7 because not only did he apologize to me, but his vice 8 chancellor came up to me and said "I'm sorry that we are going 9 to keep him from coming because I know how strongly he 10 wants to come to be there with you." 11 I suspect hc -.ot to me because in one respect, not 12 only because I was going to be here, but as some of you who I' may have better memories than others -- and I am surfacing 1 4 this becase there may be some of those of you who remember 15 that when the discussion came of the possibility of turning 16 the Florida region into two regions or three regions, I was 17 one of the individuals that felt that that might be the 18 appropriate direction that they might have to go in the 1 9 s ate of Florida, and I was coming off of the base of having 20 grown up in that area and with some continuing knowledge 21 of what is going on in that area, and feeling that t e 22 direction we were going and trying to superimpose on the 23 state of Florida might end to the destruct of the Florida 24 RMP. I would have to say that what has come out of the @co@rat Reportefs, Inc. 25 site visit report and what lias happened in the state I indicates to me that, by god, I am wrong once in a while. 2 It is certainly clear from the enthusiasm of the-site 3 visit. 4 I might just read you the very brief note that 5 Mac gave me, which said simply: "Bill, were I giving my 6 report to the review committee I would enthusiastically 7 describe the great strides made by that region in solving the 8 messy problems they were faced with two years ago." And 9 as Warren reminded you, he was on the site visit originally. 10 "They have realistically and forthrightly come to grips 11 with the4r problems at.-' have solved a great many. Both 121 Bland Cannon and I feel strongly that they should be approved 11 at the level requested save for negotiation re the renal 14 project ard approtal of t'-3 developmental component. it 15 is now a B plus region. Mac. 16 Discussion. Yes, Leonard. 17 DR. SCHERLIS: Just a question. Perhaps I missed 18 it. The grantee institution has Dr. Hampton listed as 19 c( 3rdinator and Dr. Larimore as the director, and I notice 20 that Dr. Hampton is listed as 20 percent effort. I was 21 wondering what is the channel of command and what are 22 Dr. Hampton's responsibilities in terms of Dr. Larimore. 23 DR. CARPENTER: My observation was that Dr., Hampton 24 sat in the back of the room-through the whole meeting, ,e - al Reporters, Inc. 25 when he was asked by Dr. Larimore to comment he did so, and bz I very effectively. And when something needed to be done to 2 put the polish on Dr..Ilampton was right there to do it.. 3 I think he works as a long time respected member of the 4 Florida community who can contact people and get things done, 5 but that he is very ready to take advice from the technical 6 people on the staff, the advisory committee, and so on. .7 DR. SCHERLIS: What does he do with his other 8 time? 9 DR. CARPENIER: Practices medicine. 10 DR. BESS: Dr. Hampton is a well respected 11 internist and formerly president of Florida State Medical, 12 has been a director of AmPak. He is highly regarded in the 13 American Medical Association. He is a good man to have on thcr I4 DR. SCHERLIS: Gives them strength in the 15 community. Dr. Larimore has the day to day operation, I 16 assume. 17 DR. CARPENTER: Right.. No question about that. 18 DR. MAYER: Dr.-Brindicy. 19 DR. BRINDLEY: May I ask you a question? 20 DR. MAY'ER: Could you use the mike, please? 21 DR. BRINDIXY: May I ask you a question on page 7 22 of the synopsis about one plan,"bsaith care services for 23 the underservea rural areas of the state whereby plans are 24 to follow the Mayo, Florida experiment', whereby medical ce*al Reporters, Inc. 25 students are sent to Mayo for training and providing this type of care." What are they talking about there? 2 DR. MAYER:- Beautiful. By happenstance it turned 3 out to be Mayo. Bob, do you want to try it? I would be 4 glad to comment on that,one because I have been involved. 5 DR. CARPENTER: Well, as you can see, the Chairman 6 and I are both excited about this. Florida is excited, too. 7 They feel that this is the new Mayo Clinic, the other one 8 being somewhat old fashioned. And it is really an outreach 9 program of one of'the medical schools to a town called 10 M&yo, Florida. They have introduced into this,very small rural community physicians-- 12 DR. 13RINDLEY: Not Rochester we are talking about? 13 DR. CARPENTER: No. Everybody is very happy, and 14 the people in the town are getting medical care they never 15 got before.' 16 DR. BRINDLEY: That's good. I just couldn't see 17 how Rochester-- 18 DR. MAYER-. I might just comment that those of you 19 who are interested in issues that relate to how can a 20 medical center effectively relate to a community which has 21 no health care and what are the impacts of that relationship, 22 this is an absolutely magnificent experiment which is being 23 well studied, and some of the even economic effects of that 24 effort have been just remarkable because Mayo has how 'Ceeal Repoiters, Inc. 25 become somewhat of a referral center which has enhanced its I trade center, and they have literally doubled the tax base 2 of the community from, the sales tax receipts and the rest 3 just in the period of time since they moved in. It is 4 a fascinating experiment. 5 I bring it up only if some of you are interested 6 in those things there is a good example to look at. 7 DR. SCHERLIS: Is there a motion on the floor? 8 DR. PERRY: I would like to make it more specific, 9 if I can, because of the specific amounts to give you a 10 feel of what it is. The current funding is for $1,355,718. 11 The total request is $2,2i3,435 including the renal. We are 12 recommending what they have requested from the $1,355 to 1 3 $1,552,706, which is an increase, including the developmental 14 of 135, of only $196,988; because they are reshifting 15 so many of their priorities,, they are phasing out seven 16 projects,, we are giving them this, and this is only an 17 increase of'$196,983 plus. And the renal project which has becr, 18 recommended at at a 250,000 level, what was requested 19 was 660,000. This has all been negotiated with Dr. Lewis 20 and the other people. 21 So it is a total increase, if you include the 22 renal, up to one million 802. 23 DR. MAYER: Including approval of the developmental-- 24 DR. PERRY: Approval of the developmental of 135. ceie,ll Repoiters, Inc. 25 MISS KERR: And the triennial status? DR. PERRY: Yes, full approval. 2 DR. MAYER: Is there,.a second to that? 3 MISS KERR: I would second it. 41 DR. MAYER: All right, discussion. 5 Yes, Dr. Hinman, 6 DR. HIN'IIAN: Is there a level established for the 7 second and third -year, because the kidney level was not 8 recommended the same for the second and third year. 9 DR. PERRY: In relation to this I believe Ed had 10 suggested to the group that this.would.be negotiable 11 as they went along. We did not establish that level for the 12 total in relation to the kidney. 13 DR. MAYER: But you are recommending-- 14 DR. PERRY: But we are recommending the movement 1 5 ahead in their other triennial as far as the total amount. 16 DR. HIN@IAN: Have you talked to Ed since the 17 discussions Monday that were- held here with the Florida 18 group, because there was a suggested figure of 187,000 for 19 the second year and 150,000 for thethird year for the kidney. 20 DR. PERRY: That woul d be excellent because, as 'you 21 see, that is going downhill rather than uphill in relation 22 to this, and they have many resources they are hoping to 23 indeed put together in this. So this is very strong, 24 and we would certainly as a sit visit group go right along f Repottefs, Inc. 25 with them. DR MAYER: Leonard. 2 DR. SCIIERLIS: I was jut3t going to'say that I>erhaps 3 we shouldn't be spec ific on the renal since that's really 4 negotiated outside, and I would certainly second the motion 5 that was made, leaving the renal item open for whatever 6 negotiation-- 7 DR. MAYER: Well, we are going to need to make a 8 recommendation to Council relative to level of funding as 9 far as the renal is concerned. 10 DR. SCHERLIS: What is the item, 240 or 187, or 11 what has been the negotiated level? 12 DR. HINMAN: I;'m sorry. Ididn't hear. 1 3 DR. SCIIERLIS: What has been the negotiated 14 level at this point? 15 DR. HIMIAN: The negotiated level at this point, 16 my understanding it was not quite the 250; it was 223,500 17 for the first year, i87 for the-second year, and 150 for 18 the third year, which would be $660,500 over three -years 19 560. 20 DR. MAYER: Bob. 2 1 DR. CARPENTER: If I hear this discussion right, I 22 think I hear that becaise the renal disease grants will not 23 be as expensive the second and third yeartliatthe regionts 24 approved level for the second and third year should be 'Ceeat Reporters, Inc. 25 reduced, and I wouldn't offhand know if you would want to 67 I go exactly that direction because this is a very strong 2 region, and the reason they phase out activities is so they 3 can phase in new ones. I have no doubt they will maintain thei@ 4 level of activity in the first year of the triennium and 5 subsequent years. 6 MRS. KYTTLE: Dr. Carpenter, if you add the 7 descending renal approval to the ascending programmatic apart 8 from that approval you come up with a 1.776 for the first 9 year of the triennium, 1.824 for the second year of the 10 triennium, and 1.863. So the total does. not descend because 11 the rest 3cends. 12 DR. MAYER: All right, further discussion or comments? All those in favor of the motion say "aye." 14 (Chorus of "ayes, 15 Opposed? 16 (No response.) 17 Robert, we thank you. 18 DR. CARPENTER: Thank you. 19 DR. MAYER: It would be iny thought since I gather 20 that there are some lengthy components relative to the 21 Metropolitan D. C. perhaps, that we try to catch Metropolitan 22 D. C. beforeva break for lunch, and then after Metropolitan 23 D. C. we break for lunch and come back and pick up those that 24 are either anniversary before'trienniuni or anniversary within .e I Repotters, Inc. , -*a 25 triennium after lunch. So I think we would like to move on 40 so I then, John, if we could, to Metro D. C. 2 DR. KRALEIYSKI: The Metropolitan D. C. program was 3 site visited this past December by myself, Miss Anderson 4 and Mr. Hilton from this committee, Dr. Ochsner from the 5 Ochsner Clinic in New Orleans, and soneconsultants, Dr. 6 Reustis, who is the former coordinator of Michigan, Dr. 7 Shapiro and Dr. Kountz, looking a a renal dialysis, kidney 8 disease program that they were proposing, plus staff from RIAPS 9 including Judy Silsbee and Jerry Stolov, and some assistance 10 from Mr. Russell and Mr. Spear. 11 A little background about this program before we get 12 into it. The area, for those of you who are not familiar 1 3 with it, centered here in the District, with the counties, 14 two counties of Maryland that are contiguous to the District, 15 two in Virginia, Arlington and Fairfax Counties, and the 16 city of Alexandria, Virginia. 1 7 The program was established in 1967 with a planning 18 grant, and it went operational in 1968. 19 At the last review committee meeting well, last 20 year at this time when it was reviewed the programvas funded 21 for a triennium with the recommended level for this opera tional 22 year that they are in right now of a million six. That 23 level was funded at somewhat over 900,000 by the R@IPS staff I 24 here, Dr. Margulies and his,.staff, and then was cut back as a ral Reporters, Inc. 25 result of the cuts across the board to 887. So that is the bu kind of Mnding they have at the present time. 2 But they do have a three year program approved by 3 this committee and by Council, and they have levels of approve( 4 funding of one six for this year, one three for the coming 5 year, and one one for the -year after that. 6 This was an anniversary application then within the 7 triennium and was referred to us for a site visit. Ana 8 they are requesting in this anniversary a developmental 9 component, a continuation of four projects, a renewal and 10 slight expansion of core, and the activation of four previously 11 approved nonfunded pro".--ts. It also included a review, 12 1 as I mentioned, of tte,@kidney project that@,had@@been developed, staiA@ @velop two !years ago, and this past 14 year was SLbmitted in a te tative form, sent back for revision 15 and now is included in this review process. 16 The program was organized with the D. C. Medical 17 Society as the grantee organization, and the Medical Society 18 when they organized the program developed a board of 19 di,.3ctors as a steering committee out of the board of director., 20 of the Medical Society, and they pretty much started out to 21 run the program from a polic.,r and fiscal and every other 22 point of view. 23 Now the reason that we were asked to review this 24 and to site visit was because of the fact that the program @ee'l Repofters, Inc. 25 has had a very stormy history. They had a lot of problems I getting off the ground, and this application again asks for 2 more money, including the kidney project, and therefore it 3 was believed that it should be looked at again. I say again 41 because they have been site visited every year for the past 5 four years, and they are really getting to be good at site 6 visits, if nothing else. 7 Now I just want to briefly review the history of 8 some of those problems to put this in perspective so we can 9 then go to our findings. 10 The problems were really in three general areas. 11 First of all, p a viable pr r o the ability get 12 gr, f putting toge.ther,-.&@hd 13 de V p g-@@ ove I organizational thrust. In their first 14 year of operation, for example, it was noted that many o 15 their projects had a hard time getting started, and in the 16 review that took place at that time byreview committee they 17 discovered that the program management for some reason or 18 other was not able to get the information out to the project 19 directors that their projects had been funded and they were 20 able to start them off. So there was some undue delay in 21 getting their projects going. once the projects were going 22 the program had a tendency to turn over all the funds to the 23 project directors and then not monitor them sufficiently 24 to be assured that they were getting anything back for it, @ceie,al Repoitets, Inc. 25 so there was a problem of control. The staff that Dr. Vlontz, who is the director 2 of the program, has was pretty much inherited from the 3 previous director, and in many cases viere not located in his 4 organization. They were located in the medical societies, 5 they were located in the hospital council, they were located 6 in the health department. And these organizations in most ca,-Q@s 7 appointed those staff members, so he really didn't select 8 them. They were appointed by these other agencies, they 9 are on his payroll, they were part of his organization, but 10 they were operating in these decentralized units. So that 11 again was a problem in terms of trying to get a viable 12 program off the ground because they were each going their 13 own separate direc@,,pn. 14 tm, sion change of RIAP again t here was ad 15 u44ue delay in their grzlsp of this new mission and getting 16 t mission stateme@ t out to,the Regional Advisory Group. 17 As a matte fact,, they floundered around,with that I 8 b are@a@@@ r some, nine or@ ten. months, and inally 19 Dr. Margulies met with them and went over the whole bit -- 20 this past summer I gather is when this took place -- and 21 as a result of that the RAG group now has a little better C) 22 understanding of what is going on, but a real difficulty in 23 changing over to the new mission. 24 They had developed a number of continuing education :e -tat Reportets, Inc. 25 programs, but they were not tied in with universities, and they were operating pretty'much through,& hospital councilt, 2 and they Were attempting to build the staff. for these continuing education programs in their own organization 3 4 rather than using the t@ients that were available from the thraf 5 medical schools in the-region. 6 They had a very difficult time developing any 7 viable programs to meet the needs of the underserved in the 8 area. And as you well know, there are many unmet needs in 9 this region. Most of their programs, however, were still 10 categorical in nature, and most of them really weren't 11 serving the needs of the poor. And this again was a concern to 12 R@ here. 13 Well, that was the general problem in terms of 14 trying to formulate a program that would meet the needs of 15 the region. 16 They have not been able to develop a data base. 17 Comprehensive Health Planning has not been terribly active 18 in the region, and therfore they just haven't progressed 19 very wall in the whole program area. 20 The second area of concern was with administration. 21 As I mentioned, the medical society was the grantee 22 organization, and initially they took a very strong leader- 23 ship role in running the program. Vhen this was challenged 24 during this past year they backed off completely and now are ce*al Reporters, Inc. 25 referring many decisions that they should be making in terms I of fiscal policy to the Regional Advisory Group. So it has 2 been that kind of a fluctuating.situation. 3 The medical society is a small organization and RMP 4 dominates it. RMP has the larger staff, more money, more of 5 everything than the medical society has, and it hasn't been a 6 very profitable relationship. 7 The services that were supposed to be provided by the 8 medical society have not been very useful, and even the 9 limited fiscal services that were supposed to be provided 10 have not come forth, and as a-Tesuit the.Regional Medical 11 Program developed their own staff capabilities in handling 12 fiscal management. 13 The leadership in the program has not been strong. 14 Dr. Wentz is a nice guy, is well meaning, I think he has 15 developed a lot of contacts in the region, he has developed a 16 lot of rapport with the producers of services; but he is 17 just not a strong administrative leader, and he has not over 18 the past years appointed anyone on his staff to fill in that 19 gap: So the organization lacks the strong leadership from 20 the top. 21 The staff members, as I mentioned, were appointed 22 by other agencies, at least in somecases, and they are busy doing eheir own thing, have been for the past two or three ars, and he has just not been able to bring them into an cost Reporters, 25! rganized group. At least that again was a problem that was I being presented to RIJPS here. The staff members have pretty 2 much their own personal interest in mind. They have personal 3 projects that they would IiJke to develop, and they have not 4 been able to relate those to an overall organizational thrust. 5 They have right now 31 gore staff members on board, 6 and they want to expand that by about five members. 7. The staff unfortunately, in addition to having 8 individuals appointed by other agencies and individuals who 9 have very personal kinds of things they want to accomplish, 10 have another component made up of individuals who have retired 11 from other jobs. And t',i whole administration of the program 1 2 and who]* hose taJe ts togethe@r has @been 1 4 Wsiit thL third e-ea was with RAG. The bylaws state 15 that the RAG membership can consist of as high as 70 members. 16 They now have 58 members with 53 alternate members that can 1 17 attend meetings if these original members are not available. 18 Most of these members of RAG are appointed again by 19 int*,)rest group agencies. That's the way their bylaws read. The 20 have some 70 members, as I mentioned, that can be appointed. 21 Sixty-five of these are appointees of various pro ucer 22 agencies. So t very little flexibility in terms of 23 how- they can@@ b ge@ their RAG structure. 24 The RAG group appeared to be relatively inactive also. te 101 Repofters, Inc. 25 We noted in the past that while they may get a large turnout I f@r a morning'meeting, by midafternoon there.'s very few, 2 less than-perhaps a third in some cases that are still'there 3 to deal with their problems. 4 They have not been able to really integrate minority 5 groups into the RAG structure, and it is pretty much 6 Mina ed, as I mentioned, by providers of services. 7 Well,, okay, these were the major concerns, and 8 these were the instructions that we had received from 9 Dr. Margulies,to site visit the program and to explore the se 10 problem areas and see how the program was shaping up at the 11 present time. And I will try to consolidate our findings 12 under those throe rubrics then, going on to some of the 0 1 3 projects that they now have in mind and the program that seems 0 14 to be developing. 15 First of all, under administration Dr. lYentz 16 has been able to bring the staff into his parent organization. 17 He brought them out of the me.dical society, the health 18 department, what have you, and he has brought them now into 19 his own organization. At least he has brought them into his 20 own organization structurally. Philosophically they are still 2 1 operating as individuals, and they are still operating in 22 terms of what their own personal interests and desires are in 23 terms of projects. So therefore what he has is a very diverse 24 group of people with varied talents now brought into an Ile* a[ Repotters, Inc. 25 organization and by the way, this caused him some space t problems that he didn't anticipate -- but brought into this 2 organization, and what he is trying to do now is to 3 solidify those talents to try to carr y out some kind of a 4 program role. And this has been very difficult. 5 He has appointed one of the members as his 6 administrative assistant, or what I think he will probably 7 call deputy director a little later, and I think this 8 individual may offer him some help in bringing these talents 9 together. 10 But his organizational chart is ill defined, people 11 are not following the organizational structure, whatever. if 1 2 they have a Oioblem they bypass their supervisor and they 13 go and see-Wentz. He has not been able to get them to really 14 appreciate how they fit into an organization structure and 15 report up the ladder to supervisory.personnei. .16 Again as I mentioned, v;e found at least part of 17 the staff members, par@,lof his@s@taff were retired from other 18 JL@y-,doesn't have a,gooo plan in mind as to and he 19 hoi@to,@phase@lthe;m out of his operation. He hopes that they 20 will retire. He is hoping this wiiJ. occur this coming year 21 for a couple of individuals. But,yet he wont take the 22 initiative to talk to them about their future role with him 23 and to weed them out of his organization. He is taking the 24 easy route again,, and the human-relations kind of approach :e lei Reporteis, Inc. 25 that you would expect, if you would meet him and talk with I him five minutes you could appreciate totally, of how he 2 is.;-going to deal with these very, very difficult problems 3 of putting that staff into some kind of order. 4 They have some good people on board, and I think 5 they have a lot of talent there if they can put it into some 6 kind of order. The good people, as you would expect, of 7 course, are getting very upset with the organization because 8 of the way it is kind of floating along and with their inabiiil3 @o even get their employees or their people that he wants o 9 10 report to them to be able to follow that channel and stop bypassing them. 12 Okay. WEJLJL, the next thing is the question of the I' medical society, and this has been at least partly resolved. 14 There :0 n(Nw a co@ittee b-en formed between the Rllp staff and 15 the medical society. They meet weekly to try to iron out 16 some of their differences. They are trying to iron out now 17 exactly what the role shouJLlbe in terms of a grantee 18 organization in fiscal management, and I am fairly --onfident 19 tht that is going to improve, that relationship will improve 20 over this coming -year. 21 The newly elected President of the medical society 22 assured us that lie is going to tive them his fullest 23 cooperation to expand Rl,,IP, and that in his estimation it was 24 perfectly agreeable to lot RAG be the policymaking body and Reporters, Inc. 25 for the medical society to act in a different capacity. They have a tentative agreement at least that the 2 program will probably move out of the building that the 3 medical society is operating in and get into a different 4 building which will give them more space, and probably also a 5 little more freedom from organizational constraints. 6 The gional Advisory,@Group has been totally 7 roio an@ized,,4v@and they have organized it now into a number of 8 working committees, and Dr. rientz believes that rki g 9 c@ittess@will involve RAG more actively in the deci ion I 0 making :an t rl3fore will be helpful in getting them to me moo- ings.and'take ar active role in the program 12 They have been only minimally effective in involving minority groups into this decisionm@ing structure, although 14 they have added on) black -oman -- her name is Mrs. Bullock 15 to tha groupi and she was very impressive to us. Unfortunatel3, 1 6 they didn,t invite her to the site visit meeting, buo we did; 17 and we brought her in and sat down and chatted with her 18 in the afternoon, and the plain fact is that she had been 19 inVtted to Join RAG some six months ago. They have not, 20 unfortunately, done a good job of bringing her up to date on 21 what RAG is all about or abolit the program. They have not 22 involved her in the decisioniaalring process as of yet. But 23 she has attended the meetings, she has made herself heard, 24 and we think in the long run she is going to be an extremely I Reporters, Inc. 25 beneficial influence to the program. The chairman of the RAG group,that is now chairman f the group, and, wasn't last year, as I understand it, 3 assured us that he fully intends to integrate all interest 4 groups into the decisionmaking of the Regional Advisory 5 Group. And through their reorganization and their formation 6 of working committees he believes that he can do that.@",.Ye 7 ay y,one of his working committees are headed by physician 8 aud &X4e@ @prOtt-y much representing interest group @encies, 9 and I think it's yet to be tested as to whether people like 10 Mrs. Bullock, who I think Will be very influential on the am, will be able to alter those committees or be progr 12 alter the decisions that come out of those committees. We 13 think that she might, but yet it's untested. 14 The RAG group during the past year have only met 15 three tinws.. They have an executive committee that issupposed 16 to handle decisions between meetings, and the executive 17 committee only met once. Again this RAG chairman assured us 18 that this was not going to be the case in the future. And 19 he did come across as %n aggressive kind of guy who will 20 make changes. Again it is of yet untested. 21 Twenty-three out of the 110 RAG members and 22 alternates are minority members. But with the exception of 23 aboutthroe of them they are a relatively passive group, and 24 it would appear to us that they were handpicked maybe that'r @Ce*,al Reporters, Inc. 25 being a little too unkind, but they were brought in there with I the idea that they weren't going to cause any waves. Mrs. 2 Bullock, on the other hand, will cause waves, and again we 3 pin a lot of hopes on this gal,. 4 ALI right, the program in itself, they have broadly 5 stated g .,,,,Ond objecti s that kind of go along with 6 what everyone else thi4s should be done 'and ref lect the 7 national interest. Their projects that they have developed, r, don't really fall into these general areas, 8 howeve 9 although the areas are so broad that-you could fit everything I 0into them, I suppose. They have few new projects. As a 11 matter of fact, the ap-tication we have in'front of us here, 1 2all of the projects have been previously approved, So I there's no now projects in it whati,3ever. 14 Thcy ha,-e asked for money for a number of contracts. 15 In fact they have asked for $700,000 in,this application 16 for contracts. And they hope through those contracts for 17 small studies to give advice to different groups to be 18 able to implement some new strategies dealing with HMO'S, 19 dr*-tling with manpower development -- for example, the 20 geriatric nurse program, this kind of a thrust. 21 Their priorities again have not been well developed. 22 Ana as a matter of fact, in loooking at the projects that 23 they are'requosting funds for here, with the R'AG group that 24 was in front of us that day :we were asking them what they Repofters, Inc. 25 thought of these projects and the priorities, and they essentially reversed many of the 'priorities as opposed to 2 what we have seen in our application. 3 Now we were both dismayed, and on the other hand 4 somewhat appreciative that this might be effective in the 5 long run. Number one, we were dismayed because of the fact 6 that it appeared that the priorities as they were spelled 7 out here in terms of projects probably hadn't been effective; 8 but number two, RAG had been reorganized, the reorganized 9 RAG had not had an opportunity to look at these projects, and 10 it appeared to us as we were dealing with RAG in that 11 meeting the day we site visited them that probably they were 1 2 going to be effective in reallocating those priorities in 13 a more meaningful manner. So we did got a glimpse of the 14 fact that RAG may be shaping up and may be willing to really 15 take this program and turn it around, 16@ Of course , in terms of a program they have had 17 a difficult time getting a thrust from the core staff because. 18 of the fact that they are all operating in their separate 19 ways. This isn't exactly true, but still we see programs 20 such as the continuing education program for nurses 21 being developed by itself, continuing education program 22 for physicians being again a separate entity. And when we 2 3 raised the issue of trying to put these together into some 24 kind of a continuing education thrust it was really a new I Repoiters, Inc. 25 thought, and they really had not done that at all in the past. They have totally reorganized their review procedure, 2 and they have an office that they call an office of Ptogr= 3 Appraisal which will be evaluating the projects once they are 4 funded and will be reviewing the projects, and again on 5 paper it looks as though it might be pretty functional; 6 again, however, it is untested. 7 In terms of projects they have some few that we 8 feel had some real merit. For example, one of the projects 9 they are asking for is a nurse midwife project that would 10 train nurses to work in the poverty areas. 11 Through their contracts they are asking for money to involve medical students and nursing students and other health students into a program in the poverty areas for two purposes, one, to got them to appreciate the problems; 15 and number two, to got them to start working together as a 16 team. And it seems as though this has somemerit. 17, The training of nurses-to work with the aged seemed 18 to have some real merit to us. 9 The HMO projects that they have in mind in terms 0 of giving groups of physicians some help, providing them information with the Hllo concept, to'help them get the 22 organizations off the ground, seemed to have merit. 23 Again, however, we felt that their program was 24 still at the embry@nic stage of develop-Lnent. Their organi- kc Olal Repotters, Inc. 25 zation was certainly minimal in terms of its capabilities at I the momenta It looked as though RAG had some promise in 2 terms of docisionmaving. But yet this all might be for the 3 future, and when you are dealing with $700,000 in contracts 4 you have got to have, of course, a much stronger organization 5 than that to be able to handle that kind of money. 6 Now with all of.those -- oh, one other project, 7 of course, that I should mention in that context was the 8 kidney disease project. This was reviewed separately 9 by Dr. Shapiro and Dr. Kountz in a separate meeting, and they 10 found that project to be very worth while. And as a matter 11 of fact. maybe at thiE time I can get you to comment on it 12 since you sat in on the meeting with them,l@l,,Itr@. @,S MR. SPEAR: My naturally poor enunciation is further 14 burdened ty some oral sur,-iry yesterday, so if you don't understand me, holler and I will go back. 16 The renal project has a history that in many ways 17 parallels the history Dr. Kralewski described for the region, 1 8 The history is one burd3ned with poor organization, poor 19 p, -inning, selfish interests expressed. And at the last 20 Council meeting, one of the last projects in hand, Council 21 said Let's take'one more JLo,ik, one more attempt to get 22 these boys to sit down and work together, and that's what the 23 kidney deal is all about. 24 Nceo,al Reporteis, Inc. It was not the first time this had been attempted, 25 and I think that had some flavor in what happened. There was another element I think that was important 2 to the flavor of what happened', and that was that a young 3 doctor by the name of Argie on the Georgetown nophroiogy 4 staff who had been talking with us for some years and 5 recognized what we were trying to say and recognized, or 6 at least agreed with the kinds of activities and directions 7 we were suggesting, had in the past had to admit to us that 8 he was not in a position to come forward with any strength 9 with his recommendation to this regional group. As of the 10 meeting in December he was the spokesman and was the central 11 force, I think, that brought the group finally together. 12 It was a very quiet meeting, one that pretty cieari3 13 through Dr. Argie's efforts as well as the R14P, had done 14 well. There its work and gotten its marbles lined up pretty 15 was a good sense of cooperation. There was an admission 16 of the need in the area, and the fact that they had resources 17 to build on, and promised to come forward with something 18 more realistic to meet the needs in the renal disease area 19 for the MYTRP. 20 Shall I go ahead and say what came up later, 21 Dr. Kralewski? 22 DR. KRALEWSKI: Yes. 23 MR. SPEAR: The plan that came forward was for 24 Repoiters, Inc. a total request of $524,000, a little more, about 525, 25 f including the indirect. This is a reductionfrom the on I application we were seeing last fall of about $384,000. It 2 incorporates a strong or certainly a stronger transplatation 3 program which was an element about which we had been hung 4 up previously. They had not pursued this as deeply as we 5 thought they should. 6 It reiterated three elements that were in the 7 original application; one, a neighborhood dialysis center 8 at the -- I have got this listed backward, I think @- yes, 9 at an Upshur Street clinic to be installed by Howard 10 University, and a community home dialysis unit at the D. C. 11 General Few spital, and L,- outer center home dialysis center 12 to be placed in Northern Virginia. Let's talk about these separately. 14 The transplantation component was a request for 15 $183,000, and is focused on Georgetown University, and 16 includes an appropriate number of staff and some very minimal 17 othor cost elements that need to.go into this. And rather 18 than detail it for you, let me give you the reviewers comment,; 19 Th.36 are comments from Dr. Kountz and Dr. Shapiro. 20 "The transplantation program now appears to be 21 well structured with two exceptions. The nephrologist, which 22 was one of the positions listed, is already on duty at 23 Georgetown, and should not be charged against RIIP. The 24 concept of the administrative. coordinator is an error. The ce*al Repotters, Inc. .25 proposal places this individual in the Rf,!P offices to keep OD records on available organs and recipients, to assist 2 patient referral, and to compile and act on third party 3 sources of payments. This position should be located at 4 Georgetown with the surgeon, and to work,closely with him. 5 There will not be a large recordkeeping activity, but there 6 will be or should be an intensive activity in developing 7 organ sources which will involve a large public relations 8 burden on both the surgeon and his assistant. It is 9 recommended that these and the other responsibilities 10 indicated be under the close control of the surgeon." 11 So the upshot in terms of money was out of 133,000 12 requested for this component the reviewers are recommending 13 106,000, a reduction of the salary of the nephrologist. 14 The transplant program is in the plan and was 15 accepted by the reviewers as a phased development of three 16 transplant sites. The initial one I have just spoken to is 17 'Georgetown. 18 There are two wzLys to go in the second year, and 19 obviously the last one to go in the third year. The second 20 year could be either Howard University, who will have a 21 trained surgeon coming on duty this coming July, a young 0 22 doctor who I am told is quite capable and has been receiving 23 a year's tra ining in Minnesota.. @orge.Washington wants to 24 get a transplant and got going. ,e I Reporteis, Inc. 25 So that in looking to the future what the reviewers of I are suggesting, they found no difficulty with this, given 2 the kinds of problems that exist in the metropolitan region 3 and given the nature of the three institutions involved. They 4 accept that premise. And so they have recommended that 5 106 of that be given to Georgetown for its kick-off activity, 6 and during this first year the other institutions will.refer 7 their patients, and have agreed to do so, to Georgetown; 8 that in the second year whoever picks up the baJLI and goes, we 9 give $100.,000, and in the third year we provide on the order 10 of 30,000, which is very close to the final year requested 11 bv the region. 12 The neighborhood dialysis center at the Upshur 13 clinic was essentially a reiteration of the plan we saw in the 1'4 request that we were looking at last fall. 15 It-is worth while to insert here perhaps that in this 16 review by the ad hoc committee and the comments which this 17 review group made to the Council it was stated that if the 1 8 region had only shown a definite focus on transplantation 19 and'had demonstrated the desire to get transplantation going 20 then some of the dialysis request could have been approved. 21 So in the review two reviewers, Dr. Kountz and 22 Dr. Shapiro, with the transplantation that has been described 23 are now quite willing to pick up these other three dialysis 24 activities and think they are quite appropriate for the needs eAD Reportefsi Inc. 25 of the community. The region suggests that there are' on the order of 2 150 patients -- this was the 1970 figure -- on dialysis in th e 3 region being treated through seven centers. The gap lies 4 in the innercity where there is little, if any, resource 5 for the innotcity residents. These dial.ysis centers, 6 essentially the Upshur clinic and the one at D. C. General, 7 would start moving on that need. 8 The ljpshur clinic would establish a satellite 9 center to which could be referred home patients whose home 10 environment does not permit self dialysis. This would be 11 what we call a satellite center that v@ould have beds or 12 reclining chairs with several dialysis machines. It would 13 be staffed essentially by perhaps a nurse and a technician. 14 There are certain requirements that are unique to the 15 District that require a physician in attendance for two 16 reasons: one, Upshur clinic is made available through the 17 Department of Human Resources-, and they don't want it used 18 this way without a physician in attendance; and secondly, 19 Med'icaid requires it for reimbursement. So they intend to 20 employ probably resident physicians to be there during the 21 evening and be in attendance for this dialysis. But those 22 people being dialyzed or using the machines would have been 23 trained to use them themselves, but would be people whose 24 't them to perform this at home environment would not parmi :e -01 Reporters, Inc. 25 home. Secondly, they want to train community physicians 2 to maintain primary responsibility for the patients. They 3 want to train people in the Northwest, central D. C. area 4 to fill the technician jobs that would be open in the center. 5 They wantto provide general renal training to other 6 physicians. They want to augmnt the city's dialysis 7 capabilities, and they want to integrate this with the other 8 activities that are or will be coming forth within the 9 region. 10 It is worth while noting that-a here training unit 11 in Iloward University will be in operation next month. And 12 they would hope with the RMP support to have the Upshur clinic 13 in operation by about July, and through their own center 14 operation have the patients trained to start putting this unit 15 into operation immediately. 16 The reviewers' comments were: "The reviewers felt 17 'it would be unrealistic to train community physicians and 18 to follow up on home trained patients. University physicians 19 or center physicians should retain this responsibility. If 20 having a physician in attendance will meet Medicaid 21 requirements then it should be possible to obtain reimbursement 22 for evening physicians and the technician services. Since 23 the Upshur patients will be trained in self dialysis supplies 24 .1,0"1 Repoiters, Inc. should not be reflected in the budget. The reviewers believe 25 the remodeling cost to be wholly out of line." They were $30,000, and they had not recededfrom the earlier application. 2 And they believe essentially all that is needed if -you 3 have a room is a source of tap N7ater and you put the machines 4 in and go to work. 5 The reviewers recommended that only minimal support 6 should be necessary to get the Upshur Street satellite. 7 center into operation. 8 The requested amount, direct requested was 78,000 9 plus a bit. The proposed amount for approval from the 10 reviewers is 30,000, a reduction of a little over 48,000. 11 This level of support, given the budget that was 12 presented, would provide half of the personnel costs that 13 were requested, all of the proposed equipment, a minimal. 14 $1,000 to initiate supplies in the unit, and just under $2,000 15 for basic alteration cost. 16 The center proposed on the grounds and in the 17 buildings of the D. C. General Hospital-- 18 DR. ttkYER: Mr. Spear, I think we are going to need 19 to ..abbreviate the last two components of this. 20 MR. SPEAR: All right, very good. Let me go right 21 to the comments. I think they are almost self-explanatory. 22 The reviewers found the D. C. General proposal 23 to be unnecessarily lavish for the patient output that was 24 being proposed, and they raised question that the output @e -Oal Repotteis, Inc. 25 levels given by the applicant was wholly underutilizing the center, and they say even though at thzt level there is a 2 question-whether enough patients could be found who would .3 have the financial support back of them to fill this unit. 4 They think some rather extraordinarily rich ... aides are 5 completely unnecessary, they see no reason for the computer 6 data bank that was proposed, no reason for some intensive 7 kinds of almost research activities that are proposed. 8 So from $175,000 requested they proposed that 9 only $41,000 be recommended for approval. This would provide 10 for a nurse, half a social worker, half a secretary, two 11 machines and related build-in, and a basic 1600 for .12 alterations. 13 The Georgetown unit which is proposed to be placed 14 in North Virginia serves essentially two purposes. 15 George town presently cannot expand on its present site. 16 It is estimated that the earliest expansion of its renal 17 unit could not occur before-five -years. In this context 18 they are being burdened by West Virginia patients who are 19 being literally put on the bus and shipped in and dropped at 20 their doorstep. And they urge d two things. Let's help 21 solve the Georgetown patient problem-. They can't expand to 22 take on any more patients at this time. And let's put a 23 center in North Virginia where there are no facilities, 24 but where there will be onough'supported, financially ce Of Reportets, Inc. 25 supported patients to help cover the West Virginia load, I vihich is estimated to be about 25 percent of the predicted loa( 2 The request is for two part time doctors, ana the 3 reviewers said we are surprised that you asked for that, you 4 have doctors coming out of your ears, perhaps you need a 5 nurse. But they didn't go ahead and specify. All they said, 6 all right, you ask 35,000, almost 36,000 for this, we will 7 recommend approval for 25,000, which would give the three 8 dialyzer machines requested, and one or more personnel 9 depending on how it was laib out. 10 The total request as recommended by the reviewers: 11 year 1. 202,265; year 2, i44,000; year 3, 30,000. 1 2 DR. ITAYER: Thank you. And just point out that 13 the 202,000 in the first year was comparable to a request 14 of theirs which was 423, which was a deletion from about 15 700,000 from previous request, which-in turn had been a 16 deletion from a million five or some such thing as that 17 sequential. 18 DR. KRALEV,SKI: Okay, want me to continue on here 19 th4n Just briefly with some of the accomplishments, 20 and one of the major accomplishments- 21 DR. SCHE-RLIS: Can we ask. questions about the renal 22 study while it is still fresh in our minds? 23 DR. KRALEWSKI: All right, if' you wish. That's fine.. 24 DR. MAYER: Go ahead, Imonvxd. ,Oeral Repotters, Inc. 25 DR. SCIEERLIS: I was just scanning the available application, and no mention was made in the discussion of the facilities at the V.A. hospital or at Bethesda Navai 3 Medical Center, and I gather there are already going on 4 active transplant units there. k -in@ e( 5 eventually of six transplant centers,,? 6 MR. SPEAR: Yes and no. We are thinking of getting the three nonmilitary hospitals started. The military 8 hospitals are going right now at developing transplant. 9 And there was considerable discussion about sharing facilities, 10 and this is hopefully down the line. But there are legal 11 problems involved for the military. So rather than deal with 1 2 that it was pushed aside. 13 DR. SCHJ,,RLIS: Lots of problems with the military? 14 IM. SPEAR: Yes. It simply was not addressed,. 15 It was discussed,, the desire to got together, the desire 16 to work together and to utilize facilities where necessary. 17 And I didn't mention that the site for the tissue.typing -- 18 the group did agree to have a single tissue typing site. it 19 mtwy be a military hospital or it may be George Washington 20 or it may be Georgetown. It has not yet been decided. They 21 simply agreed they will determine on one site. And the 22 V.A. could do it, Walter Reed is willing if they can overcome 23 their problems, or these other hospitals. If RMP support 24 is given there will be one transplant site. Repoiters, Inc. 25 DR. SCHF.RLIS: one transplant site? MR. SPEIR: I'm sorry, one tissue typing site. 2 DR. SCHERLIS: And probably five transplant sites? 3 MR. SPEAR: Very likely. 4 M. SCHERLIS: Since we have been subjected to 5 the discussion I feel that we have a right to participate in 6 response, and I must register a strong feeling that if we 7 are talking about regional cooperative ventures as being, 8 I assume, still one of the hallmarks of RNIP, I must 9 express a great deal of concern about having five transplant 10 centers unless I can have some explanation from Dr. Hinman 11 possibly, or one of his staff, as far as what they really 12 project the needs for transplants in this area. 13 1 equate in many areas of medicine, particularly 14 in such areas as this, the fact that you have to do a certain 15 number to maintain competency and,low morbidity and mortality. 1 6 Maybe we shouldn't discuss this since it has already been 17 passed upon, but since we have been subjected to the 18 information at one end I think we can respond at the other. 19 MR. SPEAR: May I comment on this, Doctor? 20 The Bethesda Naval Hospital has been designated by 21 the Navy as its transplant center for the Navy. Walter Reed 22 has been designated by the Army to be its transplant center 23 for the Army. The representatives of these groups who were 24 there said we want to be with you fellows, and the fact that ;e -01 Reportets, Inc. 25 you got organ procurement going we will have to use your I services,, but until we have met our needs with the military 2 we can't do much in the community. 3 DR. SCHERLIS-. But the V.A. hospital works with which of the medical schools? 4 5 MR. SPEAR: George W@-hington, I believe. Am I 6 correct? 7 DR. SCliERLIS: Aren't there shared facilities there 8 in many of the areas? I would assume if this is the usual 9 V.A. organization it is dependent on medical school 10 affiliation, and usually one would not choose to develop two 11 transplant centers, one at the affiliated medical school 12 and the other the affiliated -- isn't this the usual-- 13 DR. MAYER: Is the V.A. currently involved in 14 transplantation? 15 MR, SPEAR: Yes, they have done a little bit. 16 Only eight were donein 1970, @nd the total for the past five 17 years in the D. C. area is only 20 or 30 transplants, and 18 most of those are line related, including military and 19 nonmilitary. 20 DR. BRINDLEY: How many are there in Baltimore and 21 Richmond and the areas around? 22 MR. SPEAR: I only know by hearsay. I don't know of 23 any immediate teams, none we have supported immediately 24 other than Richmond, with whom Georgetown has become ce I Repoiteis, Inc. 25 affiliated. There are two transplant sites or renal sites in I Bait imore 2 DR. IIAYER: Dr. Thurman. 3 DR. THURhiAN: The point Dr. Scherlis has raised 4 is a good one, because do we really need three transplant 5 teams in the city of Washington other than those that are 6 already established? And we asked the same question 7 yesterday about Philadelphia because we are also going to 8 have them coming out of our ears up there. 9 MR. SPEAR: I can only answer that, our own wish 10 in this building is that there be one good one,.big one, 11 active one. 12 Dr. Kountz, who is a very active transplanter, does 13 over 100 a year personally in San Francisco, when posed 14 this very question said "yes, given the @letro D. C. 15 difficulties, complexities and population, and the nature 16 of the institutions, he would agree to it in this instance. 17 DR.THURIIAN: Don't -you think the last part is the 18 most important part, because one hospital could do all you 19 are projecting, so the nature of the difficulties is the 20 important-- 21 MR. SPEAR: Dr. Shapiro made the point that three 22 institutions of t his size and this independence must maintain 23 their service, have transplants. Whether we should pay 24 for it may be another question. Repoitets, Inc. 25 DR. SCIIERLIS: I think we have to separate from I this what is clearly our involvement to make sure there is 2 an adequate delivery of such a need as distinguished from the 3 need of a teaching institution to be involved with certain 4 programs as far as teaching needs are concerned. I think therc 5 is the probability of there being a strong distinction in 6 this regard. 7 DR. MAYER: Lot me just make sure that I am clear 8 and the committee is clear, the recommendation vis-a-vis 9 transplantation was 106,000 in the first year in order to 10 got -- I gather it was Georgetown moving -- iOO,000 in the 11 second year to move the second one, with presumably the 12 106,000 being pulled out of the Georgetown program, it is 13 one year funding; and then 30,000 in the third year toget the 14 third one moving. 15 I guess the question that you are raising, Leonard, 16 is in the transplant area the appropriateness of our 17 suggesting funding of more than one center. 18 DR. SCIEERLIS: Yost and the way that we are using 19 these funds is really as a direct means of getting three 20 additional centers, one I guess primed further, and the other 21 two off center. And I really question the decision of the 22 task force that looked at the renal problem. 23 DR. HESS: I can see some real practical problems 24 in trying.to lump the military in with the civilian. I 1 Reporters, Inc. 25 think there is a justification for separating those. But if we take the civilian as a separate category and the one with 2 which we are primarily concerned, which could include the 3 V.A. -- I don't know what the problems are in terms of 4 cooperation between the V.A. and let's say D. C. General, 5 but if we separate out the military and look at that and 6 say that is our primary focus of concern as RUP then I 7 don't think it makes sense to promote and facilitate 8 unnecessary duplication. 9 DR. @IAYER:, All right. Further discussion on the 10 renal? We will zome back to it when we come to the 11 recommendations specifJ-aily within the whole recommendation 12 of the project. 13 DR. KRALEISKI: Let me co,@.ment just briefly on your 14 response of why yet were s,,bjected to this information. We 15 were directed by-Dr. Margulies when we went on this site 16 visit to review this project and to bring it to this committee 17 in the form of a recommendation one way or the other for 18 this region in terms of their total program. He, or his 19 st@f, had selected site visitors to take a look at the renal 20 program which, as I mentioned, were Dr. Kountz and Dr. Shapiro 21 and Mr. Spear, and they met with this group in the afternoon 22 while we were carrying on th,3 rest of the site visit. And 23 Dr. Shapiro believes that the program was a good one 24 and that we should bring up i,n this form in front of the e Reporters, Inc. 25 group, and that was in accordance with the instructions from I Dr. Margulies. So that's why the information was being 2 presented. DR. THURMAN: He survived it. 4 DR. KRALEWSKI: He did, 'yes. 5 Okay, let me go on here Just briefly with a few 6 other of the accomplishments that we have noted. 7 They have made progress in reorganizing their 8 program. Of course, they have brought some of their staff 9 together. They have reorganized RAG, they have reorganized 10 their review of title projects, they have reorganized the 11 evaluation of the projects and monitoring of the projects. 12 All of this, thougn, has been accomplished recently and will 13 be in effect only for tiie future. 14 They havi voiced some interest in putting their 15 continuing education programs together into more of a thrust 16 after some discussion with us, but they have made progress 17 in continuing education, and particularly in terms of 1 8regionalizing their efforts with the hospitals, because they 19 have been working pretty closely with the hospital medical 20 staff members in the region for a continuing education project. 21 They have made progress in a patient education 22 project through the outpatient services in the h@pitals; 23 and they have a young gal who is a nurse o core staff 24 working on that, and she is fairly offecti 1 Reportets, Inc. 25 They have been pretty succ in finding other I funds for their projects once they have phased them. With .2 the cutback in funds during this past year they have transferred 3 many of their projects over to other funds. In fact there 4 were six or seven of them that they found other funds to 5 support, six or seven projects. 6 Now the reason they could do some of thist of course, 7 is again through the relationship with these many,'many 8 agencies that ar th them on the' i CO itt 9 So locking in with those agencies, of course, works both 10 ways. It has been a limiting factor to.them in terms of 11 their flexibility, but they have been able to get-the support 12 from those agencies when they needed the dough to pick up 13 some projects that were being phased out from RMP funds. 14 They have, of course, good relationships with many 15 of the provider agencies, again through the RAG members being 16 part of those agencies. 17 They have worked to-tr,y to develop a Comp planning 18 B agency, not too successfully, but they have made a little 19 proiress on it. And they have a good relationship with 20 the developing A agency. 21 Their short term pay-offs I suppose in our estimation woke few, with the exception of promise again 23 from these contracts whore they could probably realize quite a -24 few benefits in a short period of time by allocating that mone,r 1 Reporters, Inc. 25 through a contract method. lui They have been able to develop some fairly explicit 2 s of operating objectives for their core staff. Th;y 3 are spelling out fairly precisely what kinds of activities they are going to be involved with this coming -year. Again they haven't got this back down through the staff members yet so 6 they are tuned with it, but they are developing these 7 instructions, and they are developing it also in terms of these 8 contracts that they hope to let in terms of how that will 9 fit in with their core staff activity. So there is a glimmer there of hope in terms of control of the allocation of 11 funds through contracts @o be able to get specific things 12 done that they need to further their program. 13. They helped develop an ahead health forum, bringing 14 together the variou7 educational institutions in the region 15 to discuss the whole problem of allied health education and 16 how they could cooperate, and this is making some progress, 17 and I think it was a useful contribution. 18 They form,3d an JiMo subcommittee. They are meeting 1 9 witl,'physicians, with hospitals, they are putting out 20 literature on it, and they are holding informational meetings. 21 Whether that will develop to any great extent is still an 22 unknown factor. 23 They have been successful, as I mentioned, in adding 2 4 at least some minority groups @o RAG, one of them being Repo;tcts, Inc. 25 Mrs. Bullock, who we think will probably have a good influence on the program in the future. 2 Well, in my summary then, we see here an orga:nizatior 3 that unfortunately has not lived up to the expectations, I 4 suppose, of our last review. They were awarded a triennium 5 grant at fairly high level. The performance is certainly 6 below that level. We see, though, that they have made some resi 7 strides in reorganizing their program and bringing their 8 staff closer together. 9 They have been visited by the staff here in terms 10 of the management review, and they have taken the suggestions 11 from that review and attempted to integrate them into their 12 organization by changing some of their organizational 13 structure and by developing written job descriptions, et 14 cetera. So they are making progress. 1 5 And I think at the moment our question, at least 16 in my estimation, is how we can help them further strengthen 17 that organization and to bring it in to some kind of an 18 appropriate level of performance. 19 And that brings us again back to the kidney project 20 because we felt, and Dr. Shaprio and Dr. Kountz felt, that the 21 kidney project offered a great deal in this regard. It, first 22 of ail, offered a concrete kind of activity that they were goin- 23 to be able to get off the ground and would give them some 24 visibility and credibility. ,e I Reportets, Inc. 25 Number two, they felt that the project in terms of ial the overall program of R?&P offered a great deal of potent 2 in terms of bringing these universities together to start 3 thinking about the development of programs to meet the needs 4 of the region, and this would be one of the first major 5 efforts, and they felt it would lead to other efforts. They 6 felt that it would be a project that would bring many of the 7 hospitals into a regionalized kind of arrrangement, and that 8 therefore it might be really a center pinning kindof 9 activity that many other things could develop off of that 10 would be very useful for the program. 11 They felt, however, that at the momen@t. -- and we ai 12 felt after our review -- that perhaps the RIIP program should 13 not run the kidney project if it was funded because of again 14 the problems that they have in their organizational 1 5 structure, but"i probably should be run by s'omeone who is 16 pro,,e dir tor in one of the hospitals. 17 With that I will ask you, Miss Anderson, to comment 18 on this. 1 9 M. MAYER: Dorothy. 20 MISS ANDERSON: I can only add a few things to what 21 John has said.because he has covered the situation very 22 well. But I think some of his key words that you probably 23 heard was that most all these things aie on paper and untested 24 and whenever we asked questions about their organization ceol Repofteis, Inc. 25 and what their plans were for the future or who was involved I in.,various committees, what was the broad approach, we would 2 always got a flood of papers. In fact everybody had to look 3 up on the sheet of paper just what the situation was because 4 they had not been so invol ved in really operating or imple- 5 menting any of these plans. 6 1 had an opportunity to meet with two groups, one a 7 group of professionals and volunteers who were representing 8 various organizations, and I asked them what do you feel the 9 PUP contributed to the community. And there was a Dr. Gins, 10 who was chairman of the Departwent of Health Care 11 Administration from Ger-ge Washington University, and he was 12 very positive in his feelings of relationship with RIIP. 13 He felt like his students had an opportunity to have contact 14 with RUP staff, ani that the RMP staff lectured to his 15 students. 16 The woman from the Cancer Society said what they 17 felt was the accomplishment was that they are able to publish 18 a catalogue of professional films that were available to the 19 co@unit-y. And I asked if this was used, but they weren't 20 sure about the answer. 21 Dr. Finertu(?), who is responsible for a hypertension 22 cliric,, said that the reason that he develo ped his clinic 23 wasbocause of problems in the community in regard to other 24 hypertension clinics, and so his clinic now was set up Reportets, Inc. 25 according to appointment so that patiODtS wouidn It have to wait all day. They were playing foliony-up for patients with @2 hypertension, and also-that they are giving patients humane 3 treatment, and are utilizing allied health professionals 4 in this clinic. And he feels that this plan, which is similar 5 to a plan in Detroit, will be very effective here. 6 In talking to the staff in regard to the developmental 7 component Dr. Woodside, who is responsible for the community 8 program aspect in this new organization, felt, too, that they 9 needed to have a thrust as far as their direction was 10 concerned. It was interesting, I thought, that'some of the 11 staff members asked us "what is a thrust." So we had to 12 be somewhat basic. She felt like the new plan of organization 13 was very good, but she had questions in her mind if someone 14 came in with an idea with the community programs whether it 15 would really go to her or to the coordinator irs 16 I had a chance also to talk to Miss Bullock, 17 and I was impressed by her a.Lso.. She said that the community, 18 had been studied to death, and that what the problems were 19 were well known, and she spelled them out, about the needs 20 for funds for education of health professionals, the need for 21 a ladder for health professionals to grow and develop 22 in their jobs, the need for satellite clinics in the community, 23 and she really spelled out all what they needed whereby 24 she felt the RMP staff had not been out in the community, ce-Fedefat Reportefs, Inc. 25 but that the community had been invited in to RMP, and she was 106 I the example of how the community was invited in. 2 DR. MAYER: Other comments? 3 DR. KRALEVISKI: I would like to make the recommen- 4 dations for funding them, because again as-I mentioned, what 5 I hoped to do is somehow strengthen this organization and 6 give this relatively weak program director some opportuniitiee 7 to further strengthen his staff. And maybe you can't see 8 thist it is pretty small, so I will just flip this over and 9 write these figures up here. 10 This past year they had $575,.626 for core, and they 11 have had $312,055 for projects. Now what they are asking for 12 here in this application was for core at $638,766. They 13 are asking for projects, $496,700. They are asking for 14 contracts at $772,061. And then they are asking for 15 developmental, $88,768. 16 We believe it would be useful -- then there was 17 the kidney project in addition to that where they were asking 18 for, as I mentioned-- 19 DR. MAYER: 423. 20 DR. KRAIX-IVSKI: It 'was over a million, and it came 21 down to 423. We think that it would be useful if we 22 would further cut back their core budget. This has been 23 reduced the past year over what it had been before because 24 of the normal cutbacks across the board. We feel if we cut e-Fe eai Repottets, Inc. 25 it back again it will give Dr. Wentz the boost that he needs 107 I to go through there and cut out the core positions that 2 would strengthen that organization. So we are recommending tilat 3 the core be cut back to 477, and that when we do that he is 4 going to have to discharge some people and he will have to 5 take a hard k.at,that,organization and come to grips with 1#z 6 p b.Lem or resign. 7 We are recommending as far as the projects that we 8 give them $205,000 so that they can continue on with some 9 of them that they have going now, and specifically also will 10 have a chance to deal with th at.nurse midwife project and 11 a couple of projects such as that that seem to be worth 12 while. 13 We recommend inthe contract area -- althoug as 14 I previously said, there is real concern over the ability 15 of this organization to handle that-kind of activity, but 16 we feel, on the other hand, it would be important for 17 Dr. Wentz if we cut back his core to.lhave@t@he opportunity,,, 18 to-build some kinds of services through a contract group,,,and 19 we feel that he probably will be able to do that, both 20 because of the fact that'RAG is becoming stronger and will 21 be able to deal with these, and because he has a@little 22 different make up on RAG, therefore should be able to 23 strengthen his organization and possibly develop the kinds of 24 things that he needs to be able to develop a program:thriust Fede ra I Repoi te r s, Inc. 25 through a.110C ti@ Now vm are recommending $125,000, 108 I ' a substantial cutback from what he has asked'for. And this 2 area in here, I think it might be worthy of some discussion 3 as to whether we should drop that a little more or keep it 4 in that general area. 5 Now we are recommending along with that the funding 6 of this kidney project at about the $200,000 level, as was 7 mentioned in this review, again because we were toldto 8 review that kidney project in this total program context, 9 and to look at it and to see how it fit into this and if it 10 made a contribution. The general conclusion of our site team 11 was that it would make a contribution, that it would help 12 them got that program off the ground, and that it was a 13 reasonably priced kind of investment in terms of allocation 14 of that money. And that would add up to a sum of just 15 slightly over a million dollars, as opposed to their request 16 for 2.1 million or as opposed to their funding level that 17 has already been approved at 1.6. 18 MISS KERR: Are we to assume, John, that you were 19 suggesting nine, the developmental component? 20 DR. KRALEWSKI: Yes. 21 DR. WHITE: A point of information. Once a triennial 22 status has been awarded can it be retracted? 23 DR. MAYER: Lot me comment on that. Lot me remind 24 you of how we got into, or of what went on that led us to :e*1 Reportefs, Inc. 25 approv ing the triennium, at least as I view it. As you may recall, that was early on in the triennial review processes, 2 number one. 3 Number two, we had a site visit report that recommen@le, 4 a level of funding significantly above the level which we 5 as a committee finally recommended, that recommended the 6 triennium and recommended the awarding of the developmental 7 component. 8 What this committee did then in the course of 9 Giscussion of that site visit information that ivas provided 10 was of those three things they took away the developmental 11 component they signifj %ntly reduced the dollars, but we 121 never got around to saying,, you know, no triennium. Now I have to say that my guess is from John's 14 comments -hcke, and having ---amembered the comments about the 15 last site visit report, is that they are further ahead now 16 than they were when we awarded the triennium in the first 17 piace, Phil. And if we are going to take it away I would 18 have to say it was our error in the first place, yoj know, 19 ra",ier than any deterioration. 20 Now I would guess if we got into a situation in 21 which there were significant alteration in a program we may 22 want to do that, but I don't think we would have a very 23 good data base in this instance to do it on that basis. That', 24 all I am saying. @e -is[ Repoi ters, Inc. 25 DR. WHITE: I wasn,lt suggesting directly that this liu I be done. I am just questioning whether it could be done. 2 h,RS. KYTTLE: Dr. lVhi.te, from my memory one slight 3 modification, when the three year funding was awarded 4 developmental component approval was withheld because of RP.G 5 worries. It was the promise last year, and so we would not 6 be withdrawing an approval for developmental component 7 this year because it was not granted in the beginning. 8 DR. MAYER: Other staff conmients? 9 All right, you have a recommendation before you. 10 DR. KRALEVTSKI: I v./ill put it.in the form of a 11 motion, if you would like. one year funding at $1,007,000, 12 site visited next year again, and then the level of funds 13 for the following year to be determined at that time. 14 DR. @LKYER: Is there a second to that? 15 MISS ANDERSON: I second it. 16 DR. MAYER: All right, discussion. 17 Joe. 18 DR. HESS: Yes. It seems to me that if we go 19 wiih that recommendation as is we have removed triennium. 20 DR. KRALEIYSKI-. We have what? 21 DR. HESS: We have removed them from triennial 22 status. And the only thing that -- well, we also need to 23 look at that in light of three other actions we have taken. 24 And if we do not remove them from triennial status it seems :e -oaf Repoiteis, Inc. 25 to me we have to recommend a budget for the second year or the I third year in the triennium, because what we are talking 2 about now is the second year of the triennial budget,-is that 3 not correct? 4 DR. MAYER: YeB. They already have an approved 5 level of funding for that third year by our previous action 6 and Councills action of a million one roughly. 7 DR. HESS: So that that's already taken care of,, 8 the third year. 9 DR. MAYER: In a sense it is, Joe. T 10 DR. HESS: his just doesn't abrogate, that's the 11 point I wanted to make. 12 DR. @IAYER: I would just like to make one additional 13 comment, and I Would have to say that in the discussion we 14 had yesterday of minority group involvement that to me this 15 is one o,.Lv the most appalling examples, because if there were 16 ever a region in the country where there are some 17 unbelievable competencies existing, you know, it's this 1 8 particular region. And the fact that they have not accessed 19 those competencies to me is a major concern, simply because of 20 the obvious gap between -- you know, the strengths are 21 really there and they simply just need to be accessed. 22 DR. SCHERLIS: I'm back on the renal bit, and 23 also having looked at some of the projects -- they have 24 this exercise project, is that ongoing, at about $75,000 a epoftets, Inc. 25 year, exercise testing? 112 I DR. KRALEIVSKI: That's right. 2 DR. SCHERLIS: That's an interesting definition of 3 priorities. I am all for exercise, mind you, but I just 4 want to mention that. I 5 The other thing is looking at even the projections 6 given by Howard University and by George Washington University 7 in response to a direct questionnaire, each responded that 8 the number of transplants projected for each of the next three 9 years is in the order of ten. And how much money was piadned 10 to be given to either Howard or G.W., $100,000? 11 MR. SPEAR: The second year figure was $100,000. 12 DR. SCliERLIS: That seems rather expensive just 13 aB the basis of operation, not even including the direct 14 cost of the procedures, namely would be $10,000 for each 15 of the procedures done there in the next three years. And 16 I assume that there were some Brownie points given to the 17 renal project because it appeared to be a unified effort, but 18 I guess they all agreed to sit down and ask for funds, but 19 I don't know how m@k,@po ing they: ha e@@done of their needs 20 in terms of being able to accomplish what has to be done.' 21 I have a great deal of reservation not on the other 22 recommendations, although I do want to qsk -you want 23 contracts they are proposing. Was that clear? ')A I DR. KRALE'4'SKT: The contracts that they are proposing? @-I e - Fedeial Repotters, Inc. 25_1 Well, they have an array of about 45 activities listed that 113 1they were going to become involved in, and they ranged 2considerably, from,helping hospitals to establish PAS 3procedure in the hospital by talking to their, medical staff, 4and so forth, helping dis tribute some kind of a calendar 5of the continuing education events that are going to take 6place. 7 DR. SCHERLIS: Do they hmie the ability to decide 8which of these contracts should be given the highest priority 9or the lowest priority? 10 DR.' KRIUXWSKI: Weil it's a risk. There is no 11 question about it. But on the. other hand, it gives them 12 something to decide with this new organization that they-have, 13 and it is a risk that we thought might be worth taking to 14 the tune of this much money at least. 15 listing are very Some of the things that they are 16 exciting, the medical student, nursing student thing, -you 17 know, things such as that. 18 DR. SCHERLIS: Do you think they will choose the 19 ones that to you are most exciting? 20 DR. KRALEWSKI: That's what we will find out 21 next year. I'm sorry to be that evasive. 22 DR. SCIIERLIS: I'm not too concerned about the con- 23 tracts. I think this may be j.ust what they need to get 24 moving. But I wonder what some of the reaction of others ce-F6detal Repoitets, Inc. T Af%nlt want to pursue 114 I that if I am the only one who is concerned about it. 2 DR. MAYER: I have the concern about the renal 3 project only in the sense of the funding in the second and 4 third year for two subsequent transplantation centers, 5 the very point that you raised, Leonard. And I think when we 6 get to a specific recommendation what I would move, or would 7 suggest that somebody move, is an amendment to it, would be the first year, but take that $144,000 in the second year and reduce it by the 100,000, specifically the second 10 transplant component, which wo uld bring.that down to 44,000, 11 and then no funding in the third year, because the third year 12 funding of 30,000 that was recommended by the group was totally for that third transplant unit. 14 DR. TTIURMAN: lo@, you realize you are going to 15 ,,depXry their only hope of a continuing cooperative effort? 16 DR4 MAYE-R: Well, I-think we need to know that. 1 7 DR. THURTIAN-. I am being facetious, Bill. 4 18 DR. MAYFR: I think it may present an interesting 1 9challenge to them. They may reloolt where they want to do 20 that transplantation under those circumstances. -21 DR. KRALEWSKI: Mr. Spear, maybe you would like 22 to comment on that because I think it is an important issue, is 23 whether there is a willingness to cooperate on this, because 24 this is much of the basis of our willingness to go along E!-Fedeial Reportefs, Inc. 25 because of the fact that it seemed as though this brought about a great deal of cooperation. 2 DR. TliURbIAN: But, John, they are talking together 3 only because they are going to each get what they want if they 4 wait long enough. Judy disagrees. 5 DR. MAYER: Mrs. Silsbee. 6 MRS. SILSBEE: I would like to ask a question here 7 because at the time that Dr. Shapiro reported to the team at 8 the site visit it sounded to me just from -your description tha-, 9 their proposal now is different from %,hat they agreed to at th) 10 site visit in terms of the transplantation situation, because 11 he was excited about the fact that Iloward and George 12 Washington had decided to get together at D. C. General and 13 would lot Iloward use its facilities, and so forth. 14 MR. SPEAR: I was Less surprised, I guess, by his 15 reaction to the question than I was-by Dr. Kountz's, who I 16 thought was wholly on one side. I can only suggest that in 17 retrospection as they iooked'at it they thought well, this 18 is workable and if.,they,@can do it, if they mean it, then 19 it's fair to go atorgnvith it. 20 I would like to state one other thing. The matter 21 you were discussing, Dr. Kraiewski -- I should t hink we would if 22 feel here in the R?4PS that they really mean to do business 23 t and ge a good transplant operation going there is no reason on( 24 can't do it, and in the first year while they are doing one ,eo.,l Repoiteis, Inc. 25 they all say they will refer their patients. And I think if I timy got one'going that is efficient and effective and does 2 the Job they will have many more patients than they suggest, 3 because the figures I have are similar to yours, only 4 indicate those dialysis patients now waiting for transplant. 5 It does not get into this whole unknown universe of people 6 out there who are not financially able to be dialyzed, but 7 will be transplanted. 8 DR. SCHRRLIS: I only have the data for each of the 9 next three -years-- 10 MR. SPEAR: That's all I have.. Butthere is more 11 than I am speaking to, and there's no reason one can't 12 satisfy. 13 DR. MAYER: Would someone care to make an amendment 14 relative to, or to extend the motion as i%@. relates to 15 transplantation in the second and third year? 16 DR. SCHERLIS: I would father the amendment you 17 refused to recognize as your-own. 18 DR. MAYER: All right, thank you. 19 DR. HESS: I will second it. 2@ DR. MAYER.,;, amendment was that we would agree to the 2 #00.0 roo nded by the group for the kidney 22 project in the firs@t@ year,, we would recommend only 44,000 23 for t second year, which deletes the second transplantation 24 center, and no dollars in the third year which deletes eporters, Inc. 25 the third transplantation center, but does permit support in the f irst and Second years of the dialysis units. 2 DR. BRIICDLEY: If experience were to show that they 3 needed to have more they could reapply for some extra funding, could they not? 5 DR. IAAYE-R: Yes. They have that option in the 6 anniversary sequence that is here. 7 DR. SCIMRLIS: With which medical school is the 8 V.A. more closely affiliated? 9 MR. CHA?MLISS: I believe it is George Washington 10 University. 11 DR. SCHE-RLIS: So they could really share these 12 facilities, I assume, and that is permissable in the V.A. 13 regulations, isn't it, that if you have an affiliation of 14 this sort your patients-- 15 MR. CHANIBLISS: There is a sharing provision in the 16 V.A. regulations, yes. 17 DR. MAYER: Shall we vote on the amendment first? 18 All those in favor of the amendment? 19 (Chorus of "ayes.,,) 20 Opposed? 21 DR. KRALFWSKI: No. DR. BESSON: 'Will instructions go to the region about 23 "@;this level of funding with advice about this amendment? 24 DR. MAYER: Oh, I would think so, Reportets, Inc. 25 Now the discussion of the motion as amended,.furthe I discussion or' comments. 2 Yes, Jerry. 3 DR. BESSON: Well, I..wonder whether it isn't 4 alsoeppropriate, in,spite of the fact that granted the militar 5 lives in a different) universe than the real world, for 6 the Council to see about some kind of coordinative effort 7 with the kind of facilities that are available currently at 8 Walter Read and whatever the other hospital is, the Naval 9 renter. And I think it would be perfectly appr opriate for som,@ 10 kind of coordinative effort to take place betwee HIJA, 11 and the Department of lrNfense. So I would like that our motion also include a request of Council that some kind of coordinative effort be initiated as far as this transplant program in this area be concerned. DR. LTAYER: All right. You understand that? 161 MR. CHA-TIBLISS: That 4D4"-t-,d be very easily covered 17 Lis 18 DR. @IAYE'-R: I guess my only I couldn't agree more 19 that they need to look at those resources and that HSIVAA 20 ought to use its strengthB, whatever they may be on the 21 federal scene, to be helpful since they are right here to do 22 that job. If in fact it turt.s out that both Walter Reed and 23 the Naval Mo6ical Center acting as the centers respectively 24 for the Army and the Navy are,not in fact overloaded by Reportets, Inc. 25 their own activities, then I '%,-hink it's one that oughtto be JL.L I encouraged to be pursued. 2 Yes, Phil, you had a comment. 3 DR. WlijiT,: May I move from the concrete to the 4 abstract, because I think in my mind if this action that 5 we are contemplating occurs we are indeed jeopardizing the 6 whole concept of a triennial review. What we have said 7 to this region or are saying to regions is we agree that for 8 the next three years you are capable of managing your 9 affairs. But our action belies that in this case. And 10 if we can do it in this case then presumably we can do it in 11 any case, and the mean4,- of a triennial award is zero. No 12 region will trust us. 13; 1 think we either have to say you are no longer 14 meritorious and we are wit-drawing it and thisis why, or 15 we have to say okay, we made an error in judgment, but we 16 will live with it for thenext two -years. I 17 IMS. KYTTLE: There are several items that staff 18 is charged with tt,,e responsibility of monitoring within the 19 trl@3nnium, and should any of these be breached it is a flag 20 that staff is required to call these things to the attention 21 for full review insofar as C-)uncil is concerned within 22 a triennium. And failure to -- well, I think the words are 23 substantial failure to achieve what was funded and the intent 24 of what was funded is one of.tliem. -01 Reporteis, Inc. 25 Judy will probab ly. be able to give you much better background on what generated the decisions this round on Metro D. C. than 1, but just by our procedurairegulations 3 they themselves would bring any region in a triennium that 4 is thought to be not meeting the goals that it was funded 5 for. 6 DR. WHITE: I agree, I think that's quite 7 appropriate that there should be sonic mechanism for it. And 8 I can understand that there may be within a region certain 9 elements of the programs that would need flagging, but 10 I think when we look at a region in which all elements 11 of the program are flagged and where we are making substantial 12 budgetary revisions, substantial suggestions to.them about 1 3 changing their personnel pattern that this is a farce. 14 DR. MAYE, R: Well, Phil, my assumption is if we say 15 in this situation a million dollars, of which 200,000 is 16 to go to the renal project, that the only restraining force 17 on that region is the 200,000 for the renal project, 18 that they would then have freedom to expend the remainder of 19 th;se funds in a way which they think is appropriate for 20 the region within the confines of things that we have 21 approved in the past. Now I think we are laying on them 22 some pretty strong suggestions, which I think is appropriate, 23 but I think within that triennium they have that freedom. 24 Is that not right, Mr. Chambliss? @-0 Reporters, tnc. 25 MR. CHAMBLISS: Yes, that is correct. They have that freedom. -2 MRS. KYITLX@: Although along those lines, Dr. White, 3 this afternoon you will be looking at anniversaries within 4 a triennium that were not site visited, did come through 5 the staff anniversary review panel, and are being brought to 6 you for information purposes, but nevertheless include staff 7 anniversary review's recommendation that words go back to 8 the region about suggestions they have within the triennium.. 9 DR. BESSON: I share your concern, Phil, but on the 10 other hand I think when the anniversary.review program was 11 first developed it really was an untested idea, and if RNIPS 12 is anything it is an evolutionary program. I think the 13 notion of remanding to the regions full authority has really 14 been untested, and we are in the process of testing that now, 15 I do have one of the programs, Alabama,. to review 16 where this very question comes up. So I think that there 17 are several aspects of that anniversary review that ;ire 18 being changed as we go along. 19 For example, we had originally spoke of anniversary 20 review as precluding project review, but that has become 21 patently impossible. We can't review program without looking 22 at the matrix of the program which is project, and if we are 23 candid about how we reach a dollar figure, which, after all, 24 is the only leverage that review committee has, we reach -*I RepoiteFS, Inc. 25 that dollar figure by careful scrutiny of the projects, I the leading projects here and there, which gives us a final 2 f igure. Now that is appropriate, I think, because we &re looking at the substance of the program in terms of project. 3 4 The second thing that has changed since anniversary review has developed has been the emergency of SARP, the 5 6 Staff Anniversary Review Panel, which I think gives staff 7 a very substantial function in the review process. And in 8 my particular region that I will be reviewing it will be 9 for review committee's function alone. We have no ac on io to take on it, and staff I think has been very close to 11 the problem, nas appropriately, I think, recommended a change 121 in funding level. But they retain, as I understood your 13 comments a little whilb ago, Mrs. K;ttle, the option of bringing it to review committee for action, 14 151 1 think it would be well for the review committee .16 to have sume clearcut idea of standard operating procedure 17 vis-a-vis the entire anniversary review process. But I 18 don't share your concern that we are going back on our 19 ori@ginal intent. I think the intent is that we do have an 20 obligation to monitor tha region and make sure that they are 21 accountable. 22 DR. MAYER: Phil. 23 DR. WHITE I have no problem with the con--ept of 24 surveillance, and I have no problem with the concept of a :e-01 Reporters, Inc. 25 close scrutiny of the application, including ail elements I MRS. SLOAN: Could I make Just one comment that may 2 be helpful in the kidney disease area? The National Kidney 3 Foundation has brought together a committee to develop 4 guidelines in the field of kidney disease, in stage kidney 5 disease, comparable to those which we have been developing 6 for the Secretary's list under section 907. They have made 7 the recommendation that unless a proposed transplant facility 8 could project a volume of transplants of 50 cases per year 9 that it was not an appropriate place to have a transplan 10 program in term-- of the safety of the patients and keeping 11 the team sharp and act4ve. 12 But rather than saying that neither G.W. nor Howard could hope to have a transpant program in the future, 14 if 'you could tie this in some way to the projected load 15 as this would increase within the District you might eventually 16 be able to jus@ fy,three transplant facilities. @I think the 17 hope of having one;l@@@eventually as-part of the medical s hoo s 18 program of all three medical schools has been a very 19 im*iortant@part of bringing this amount of cooperation 20 together. 21 SISTER ANN JOSEPHTISE-: May I ask just one question 22 relative to this and maybe relative to Dr. Margulies' 23 remarks thi6 morning? I recognize that a significant sum 24 of money has been appropriated at the present time for .ce eal Reporte(s, Inc. 25 treatment of renal disease and that there is going to be a of the application which incorporates project, at the 2 time we come to these decisions, That doesn't bother ine. 3 What bothers me is that by our actions here in reference 4 to Metro D. C. we are saying %ye didn't really mean to 5 give you triennial status last -year and therefore we are 6 going to be meddling in -your affairs, we are not going to 7 tell -you you are no longer triennial, but indeed we are not 8 going to let you behave in that fashion. And I think this 9 is ridiculous, that we either say you don't or -you do, and 10 I think thing this precludes the staff raising flags about 11 certain kinds of program elements. But when you have this 12 substantial amount of concern it's a totally different kind 13 of picture. 14 DR. BESSON: Viall, the other aspect of this, Phil, 1.5, is that we make decisions very often on promise, and t re is p6 ve y@@obv@ious@@gu.,I@f between promise and performance @ki 17 as is manifest here. Viell, I think it is appropriate for 18 regions to,know that they are accountable for their promises, 19 and I think it is perfectly appropriate for RMPS to hold 20 them accountable with performance, so that if this is going 21 to be interpreted by regions peripherally that they have 22 to measure up, well, that's fine. Thre's nothing wrong with 23 that. I can live with that very easil-@. 24 DR. MAYER: I guess what I was trying to say Reporters, Inc. 25 earlier, Phil maybe I wasn't communicating clearly enough -- is that what we are doing is arriving at a 2 suggested-funding level as it relates to the second yeiLr of 3 the triennium. What they do is still a matter of significant 4 judgment on their part about that. 5 Yes, Sister.. 6 SISTER ANN JOSEPHINE-. Let me ask a question I 7 think is related to this, I would' like to ask what has 8 happened to the management audit that was inaugurated? 9 MR. CHAMBI,ISS: That's a good question, Sister. 10 Those are going forward and the pace is being intensified. 11 This region has already had a management audit of its 12 activities. 13 SISTER ANN JOSEPHINE: Has the management audit 14 prepared them for possibly recommendations that will 15 indicate they are not living up to their commitment? 16 MR. CTIAMBLISS: The management audit did in fact 17 point out their weaknesses, which some of the areas you dis- 18 cussed broadly were touched on. 19 DR. KRALEIOSKI: And as I mentioned in the accomplish- 20 ments section hero, they have i mplemented some of those 21 suggestions, particularly the ones dealing with personnel policies and the ones dealing with their organizational chart. 23 MR CHAMBLISS-. And pulling the core back in. 24 DR. @ALEWSKI: Pulling the core back in. Reportefs, Inc. 25 SISTER ANN JOSEPIIINT, Pursuing this a little furthe I are there capabilities in the staff review that 2 unsatisfactory performance can be flagged early enough so 3 that a management audit could be made and be helpful, be 4 supportive maybe to the recommendations of a site visit 5 team and prepare the region for the recommendations that 6 will be made? It would seem to me if these things occurred 7 simultaneously then it would begin to be effective in the 8 total process. 9 MR. CHA@MLISS: The management audits are now on a 10 schedule for covering all the regions. It so happens we have 11 passed this one already. But certainly if there are elements 12 in the program that need management audit attention at any 13 point in the program I think the management audit team would 14 get back in. 15 DR. BESSON: Was the management audit available to 16 the site visit team prior to its-- 17 MR. CHAlfl3LISS: In fact it was. 18 DR. BESSON: Is it available here in the books? 19 MR. CHAI@ABLISS: It may not be in your books, but 20 it was made available to all the members of the site visit 21 team prior to the site visit. 22 DR. BESSON: I have never seen one. I wonder whether 23 we could see one. 24 MR. CHPIABLISS: No problem at all. -I*, Reporters, Inc. 25 DR. MAYER: Any further questions on the motion? I pu@h for transplant and renal dialysis. However, it may 2 well be that when we find out how many candidates do O)tist 3 if the program is expanded and the fantastic cost of the 4 program, we will find that we won't be so energetic in 5 pursuing this whole thing. In fact I have real fears that 6 we will move in the area of a philosophy comparable to 7 euthanasia as we begin to look at these candidates. And 8 I wonder if we shouldn't take into thinking -- there isn't 9 anything we can do about the policy, I know; but even as 10 we develop our own philosophy here, that we may not always 11 be this enthusiastic about developing all these centers, 12 and maybe heed to look realistically at what is a realistic 13 case load to support a center, and this would be of great 14 concern to me. 15 DR. MAYER: All right, further conbnents? 16 Everyone understand the motion? 17 All those in favor of the motion say "aye." 18 (Chorus of "ayes.,) 19 Opposed? 20 DR. WHITE: Aye. 21 DR. MAYER: All right. It will be duly recorded. 22 Lot me suggest that we make every effort to be back 23 here by about a quarter of 2:00 if we possibly can in order to. 24 got through the remainder. OReportets, Inc. 25 (Whereupon, at 1:15 p.m., the meeting recessed, 0 reconvene at 1:45 p.m.) VLAI,@ILI 0 0 0 0 AF'IT,,Rl@DON SESS ION 2 (JL:45 P.M.) 3 DR. MAYER: We are going to. make one small 4 modification in the schedule and move to Susquehanna Valley 5 and honor the plane J. Warren has to make to Buffalo 6 this evening. 7 DR. PERRY: Thank -you, Bill, and special thanks 8 to Miss Kerr for permitting me to go ahead first. 9 Susquehanna Valley RMP is currently in its 03 10 operational -year. It is functioning at.$480,405, and they 11 submitted an 04 request for a million four. 121 DR. SCHERLIS: May I interrupt -you just a moment? 13 Do -you want us to fill out for the others coming up the 14 same forms, or are they only necessary for the ones we 15 have the regular review of? 16 MRS. KYTTLE: The rating sheets should be filled 17 out for your anniversary prior to the triennium. 18 DR. SCHERLIS: Intermountain and Susquehanna? 19 MRS. KYTTLE: No, Intermountain and Susquehanna are 20 regions that are anniversaries prior to their triennium. 21 They have not received a prior rating from this committee. 22 SARP rated, and I have the ways in which the SARP members 23 arrived at that rating, and I was trying to get back before 24 you started to talk this over with you a bit. This is what :e-*,al Reportefs, Inc. 25 we wore kicking around. For anniversaries prior to triennium they need to 2 go to Council with a firm recommendation of a rating. 3 We were wonderi ng what the comniittee's assessment 4 would be of a procedure van creb,y SARP would rate; if you would 5 wish, vie would show -you how SARP arrived incrementally at 6 the total rating on the pink street you have before -you. If 7 you would want to affirm the rating that SARP has given, or 8 if you would want to change it; we are not trying to color 9 your thoughts in that line. 10 MISS KERR: I would have only one comment relative 11 to your oliestion, Lorr,"ne, and that is that I personally 121 on Intermountain have no handle other than the written word which the staff review and SARP has given me, plus this, 14 plus their application, ar4 my interpretation may not be 15 a fair one. Now I will be asking for imput from the staff 16 members involved, but since I have never been to this region 17 on a site visit I have to depend largely on the written 18 word. And I just want to throw that in as a potential 19 fo' perhaps not a fair evaluation or interpretation from me to 20 this group. 21 MR. CHA-TIBLISS: WeLl, we would certainly hope that 22 an overview of the region could be augmented by knowledge 23 that resides either on the committee or in the staff on 24 which you could base some rating. 111.1 Repotteis, Inc. 25 MISS JERR: And so -you are suggesting then that we I do rate? 2 MRS. KYTTLE,: Well, now this is what I want to 3 ask you then, Therefore just thinking of Intermountain at 4 this time rather than the larger question, would the 5 specific ratings of the Staff Anniversary Review panel 6 assist you? Would you like to see them. 7 MISS KERP,.: I would like to -- after the presentation 8 and after the discussion if there are discrepancies maybe, 9 if there are some major questions or gaps. 10 MRS. KYTTLE: That's a good base. All of the 11 anniversaries have been reviewed, even those within the 12 triennium, and,have been assigned ratings. .13 MISS KE@RR: Could you report to us afterwards what 14 the average was or what the number assigned to that was, and 15 then we can-- 16 Individually? MRS. KYTTLE: 17 MISS KERR: N6, as-a group. 18 MRS. KYTTLE: I can do both. 19 DR. MAYER: Lot me try a suggestion, that since 20 SP.RP will have arrived at some ratings o n the anniversaries 21 prior to triennium, and I assume -- will they have done .22 anything on anniversaries within the triennium? 23 MRS. KYTTLE: Both. 24 DR. MAYER: All right' they have done both, I Repoiters, Inc. 25 guess, just to throw it out for discussion, that perhaps if this group had those ratings available to them to look at while we are going through the review process that we 3 might wantto raise some discussions about particular areas 4 which we may have some feelings of gross discrepancy, but 5 that we would not attempt to evolve a separate rating for 6 those that are anniversaries or anniversaries within 7 triennium. 8 Now how does that grab the committee? Is it 9 appropriate? 10 MRS. KYTTLE.: Could I add something to that? In 11 an effort to get -your feeling of -- you know, this is 1 2 only our second, and really the first full time that we have 13 seen anniversaries in this light -- in our effort to got to 14 you materials that would help you in -your reviews of 15 anniversaries that had this prior review, these ratings Come Ln 1 6 two forms individually, both raw and weighted. And I would 17 like to get your feeling about whether both documents or 18 either document sent to you at the time the other papers 1 9 areagnt to you would be of assistance to you. 20 DR. PERRY: I think I would have been happy to. have 21 seen them. I have th total that came in -- 'you know, on. 22 the pink sheet. I would have been very pleased to have 23 seen the other. 24 Again as Billy has said here, I have been to that -*I Repoiters, Inc. 25 region, but I am responding at this point to the printed I word, and that kind of revieNv from those people that have been 2 much closer I think would be of assistance to us. 3 MRS. KYTTLE: Mr. Chambliss, in an effort to assist 4 the discussion may I pass them out now, so it would perhaps 5 generate-- 6 MR. CHAIMLISS: Indeed so. I should think so, And 7 we would like to say that the SARP ratings are in no wise-- 8 MIS$ KERR: Are binding? 9 MR. CHAMBLISS: Beg your pardon? 10 MISS KERR: Are bindi ng? 11 MR. CHAMBLISS: No, indeed, they are not. 12 MISS KERR: In no wise are binding? 13 MR. CHANIBLISS: Yes, they are simply for your 14 augmentation if you choose to use them. What,we are trying 15 to do is to get as many regions rated. as we can; as we can 16 get them through the process, then our basis for 17 comparison will be much greater. 18 MISS KERR: Well, in essence then unless we have any 19 glar'ing opposition to this we are really supporting SARP's 20 rating which will then be its of ficial rating for the 21 moment? 22 MR. CHA.KIBLISS: If that is your pleasure, all right. 23 But again that is left to this committee. 24 MISS KE-RR: That's what I mean, unless there is. @e*1 Reportefs, Inc. 25 MR. CHA?,IBLISS: Yes. I MRS. XYTTLE, : It would constitute either -your 2 modification or your affirmation of a rating that would hold 3 until the next anniversary. 4 DR. BESSON: But that would be for the raw data 5 rather than the final figure? We Would have an opportunity 6 to inspect the raw data rather than just the single weighted 7 score? 8 DR. MAYER: Right. Yes. I gather that's what they 9 wore saying. 10 All right, why don't we just move along and try it 11 and see how it works, ar, I guess it's like everything else 12 in here, policy finally evolves out of dealing with the real 13 world. 14 DR. PERRY: Susquqhaiina Valley, as I started to 15 say, is currently on its 03 operational year. 16 Geographically this is the central Pennsylvania 17 area, with Harrisburg, Hershey as.the focal point. 18 I did have the opportunity of participating in the 1 9las" site visit here at this region. At that time -- and 20 Susquehanna has quite a history of problems -- there was, 21 the site visit group believed a lack of strong leadership 22 anywhere, the coordinator, RAG, medical school relationship, 23 and so forth. 24 There were some major questions asked about the ,ce-Oal Reporters, Inc. 25 relationship bet@yeen the region, if you recall, andthe grantee, the Pennsylvania Medical Society. 2 The weakness of the RAG was emphasized time and 3 again. Continuing emphasis in the region had been placed 4 on categorical and what appeared to be quite separate 5 projects with no evidence of program planning. 6 The noninvolvement of the Hershey @ledical School 7 although repeatedly requested liaison had been requested and 8 had been looked at, was noticeably consistently missing. 9 The absence of nursing andallied health imput, and 10 although their continuing education program in that area 11 emphasized this, there was no voice and little relationship 12 in any decisionmaking or committee relationship. 13 There was a concentration on subregional development, 14 And although there was recognition of thisstrong relationship 15 of individuals throughout the region.in various sections, 16 there was little,, if any, regional direction. 17 There were questions raised about how decisions were 18 made by the RAG because there was evidence that practically 19 nothing had been turned down in the history of the program. 20 Okay, that's a pretty dark and bleak picture that 21 1 painted here. But at this point there seems to be some 22 light on the horizon, and in terms of these kinds of negative 23 statements I would like to attempt to indicate what in the 24 written report Susquehanna has moved on so far to remedy some -01 Repot ters, Inc. 25 of these weaknesses. I Number one, and of primary importance and all of 2 us,I'guess, recognize the importance of leadership in a 3 program -- the replacement of the lay coordinator with a 4 physician who will assume this post January lst, just a 5 week or so ago, is of major impact here and major import. We 6 hope impact. 7 At the time of the site visit great concern and 8 it has been expressed for several times at the capacity 9 of the past coordinator, recently past, to speak up and to 10 be heard in any way with the Pennsylvania Medical Society. 11 He had formerly functioned as the executive director of the 12 Pennsylvania Medical Society. When he moved to the other 13 position they were not sure in any way that he had a really 14 major leadership role and voice to make. 15 As-of January I Dr. Joseph.T. ichter will be 16 taking -- I'm not sure I pronounced the name right, I-c-h-t-e-Y 17 a pediatrician, attended the University of North Carolina, 18 got his M.D. at the University of Pennsylvania, has accepted 19 the.position and is on staff in the region. 20 There is a vacancy on the core staff for the 21 position of Assistant Director for Program Services. The 22 nursing staff position is still open, has not been filled. 23 So there is a capacity, an opportunity for the new man o 24 make some appointments that should strengthen core and give @e-Oal Repoiters, Inc. 25 him a working relationship there in the program. The core staff, those of us that met them -- and I recall several of them.very well -- and this is in the 3 report of the staff review, the staff anniversary review 4 that has been handed to me -- great confidence in a competent 5 though small core staff. This core has carried on in t 6 past few years, and some of us wonder how, with some of the 7 lack of leadership that I think some of us feel has been 8 present there. Even during this last matter of months 9 I am sure it has been core and such that has developed the 10 application,that has put some of this together. There are 11 some strong evidences there of change. 12 Number twop in relation to RAG, RAG has also 13 appointed a new chairman. In the staff report, those who 14 have knorn him and met him and seen him in action -- and 15 again I recall who he is -- another,member that I had lunch with,today indicated she remembered him also -- the new 17 chairman of the RAG, again showing change in response to 18 some new actions there. 19 RAG for the first time has appointed a planning 20 committee. This had been recommended at our last site 21 visit. So a planning committee for the first time has come 22 up. 23 The new RAG chairman has expressed the desire which.-- 24 you know, this goes back to the early statement I made -- but D-*, Reportefs, Inc. 25 to spell out the specific relationship between the grantee I 137 I agency and the RAG. id it taite to get to that? 2 Okay, how many years d 3 But they are willing to spell that relationship out. 4 in relation to the approval of programs and the 5 assigning of priorities and such, we still have major question3, 6 and I believe these are some of the things that the new RAG an] 7 certainly the new director of the program must get involved 8 in at once. 9 The repnrt indicates that RAG is studying its 10 composition. This is another positive.. Many of us were 11 concerned about the con.,asition of that RAG. 121 Although the nonwhite population is six percent, the@E are none on the core, none on the project staff, one of 34 .14 on the '.RAG, two of 493 on -ther groups and committees. There 15 are some opportunities certainly for action there. 16 There is still a major question of relationship 17 'that has not been spelled out yet with Hershey Medical School, 18 although we have the fixst evidence indicated here that 19 th.y will consider -- and I am sure this is true since indeed 20 a position has been found for this physicianpa faculty 21 appointment for the physici&j coordinator, We hope this 22 moves ahead so there is a definite relationship there. We 23 will have to wait and see if this indeed does happen. But 24 again this indication from Hershey that they are willing to ,e - ,I Reporters, Inc. 25 look this way is strong. If you recall from our past review,,it has not been 2 statements'of negativism from Hershey, for they have been the 3 location for quite a few continuing education programs -- I 4 remember specifically a physician assistant, well attended 5 conference that they have had, programs of this kind. it 6 has been the great involvement that Hershey has been involved 7 in in getting started itself, and their unwillingness to 8 commit meager resources and such to anything else at this 9 period of time. They have not looked at it as a unit where 10 could strengthen each other together, which, of course, would I I have been ideal. 12 Although regionwide planning is badly needed -- and 13 I spoke of the 'disparate-ptojects and the problems in terms 14 of putting a region together -- the new coordinator -- and 15 I am sure he will find this out very soon -- has available 16 some very excellent resources in the very active local 17 advisory groups. They speak quite openly about -- they are 18 a grass roots group, everything happens in their program and 19 has'in the past in the grass roots. 20 Many of us were extremely impressed with the young 21 physicians that we met from the various district committees. 22 Here is a resource that the new director, the RAG needs to 23 bring in spelling out a role, a leadership role, the ways in 24 which these men can become a much more positive influence. In I Reporters, Inc. 25 the past they had very little relationship to the region other than what they could do out in their district, and in that 2 case it was a separate kind of approach, These people 'need 3 to be brought into a total relationship. But there's strength 4 and there's resources there to work with. 5 At the last meeting there was no data base of 6 any kind, the last site visit, there was no data base of any 7 kind;reported in the proceedings here and in the application, end 8 it is a bright spot certainly, in,cooperation viith,-alsocial 9 epidemiologist from Hersey a data base for the region has 10 been developed and published. 11 What is needed certainly, I believe, is a major 12 commitment of assistance from RMPS here. This has been 13 spelled out in the recommendations made. I see a comment here 14 that Harold has put on the outside of these,,Iliet's get in 15 touch with this man immediately and work with him as closely 16 as we can," and from comments that were made -yesterday the 17 approach has already been made. I notice someone, they said, fr( 18 the staff is there today. He is willing, eager to come in 19 and'work with RIEPS. He wants to take a little more time to 20 assess his own resources, his own region, before he starts 21 to move. 22 In terms of recommendations -- and to go down the 23 line of all of these I think in the period of time that 24 we have,it is going to be a repeat of what we found in that :e -of Reporters, Inc. 25 region before. I think the important thing to make of the I recommendations and here I am leaning very heavily on 2 the staff review recommendations, and I do concur certainly 3 with them. 4 Number one, to provide an initial award for the 04 5 year of $480,405. This was the commitment for the 04 -year 6 as well as the current level of funding, the exact amount. 7 I think it needs to be made clear, as the staff 8 has recommended, and looks like an excellent way of doing 9 this -- made clear to the region and to this new coordinator 10 and to the RAG that's trying to make all kinds of changes 11 that this amount can be allocated by the region in the most 12 effective way possible to chart this new course for the region. 13 Number two, to recommend that the director of 14 RLII>S be given the authority,to allocate up to 100,000 to 15 this region during the 04 year if it is determined by staff 16 that this can be effectively used for regional and program 17 development. That total, were it to be given, would be up 18 to an amount then of about $580,000. Regional and program 19 development certainly deserves this. They have the programs, 20 the staff -- and those of us who recall the projects that 21 are already in operation, we are not too impressed with some 22 of them, some of them have had minimal effectiveness in 23 various ways, but this would put the RAG and the director on 24 the basis of an opportunity to move ahead and change. eportets, Inc. I feel that it is absolutely crucial that RMPS 141 I 'move with this individual in every way possible in terms of whatever assistance can be given. 3 We would also disapprove the developmental component. 4 And I would like to have Judy, any of the other people 5 who are familiar with the region, to respond to this since there 6 was not a site visit, anything that I might have missed in the 7 recommendation. 8 MRS. SILSBEE: You didn't miss anything. Dr. Ichter 9 is on board. I understand he does have a Hershey faculty 10 appointment, and as soon as he gets his feet wet and goes to 11 St. Louis he wants to talk to Dr. Margulies. 12 DR. MAYER: All right, comments? 1 3 1 have one to mal4ie, I would just like to suggest -.14 that in recommendation number two, that is the availability 15 of iOO,000 in the 04 year, that it be clear that in making 16 those dollars available there is no implied.commitment in the 17 05 year above and beyond the $580,000 issue. Because what 18 I am saying is if they com,.nit.that, all tha t 100,000 in the 19 last quarter, you know, in theory one could be caught in the 20 begining of the 05-year with an $880,000 kind of commitment, 21 and I just think care needs to be given in dealing with that. @22 DR. SCIIERLIS: For my own information would 23 Dr. White comment on project number 28? 24 DR. WHITE: Later. Reporters, Inc. 25 DR. SCHE@RLIS: What's tliv-t? DR. WHITE Later. I haven't looked at it. 2 DR. SCIIERLIS: It's just a small paragraph. 3 DR. WHITE: I don't even see it. 4 DR. MAYER: What page are -you on? 5 DR. SCHERLIS: Last page of the orange sheets. 6 DR. WHITE: Ridiculous. 7 DR. SCHERLIS: What? 8 DR. IYHIIT, Ridiculous. 9 DR. SCI-EERLIS: Thank you. 10 DR. PEITRY: These ar e the recommendations that have 11 been made also by -- an I recall this specifically -- by 12 the Last program. This was the project,..'if -you go back 1.@ into this region, that concentrated completely on 14 coronary ani all ti,ese var-,tus -- and- we have been criticizing 15 them right down the line. This is one of the reasons why 16 in the committing of the money we are saying for god's sake, 17 let's look at new objectives, new-goals, in terms of what you 18 are coming up with. 19 .* DR. SCHERLIS: In view of Dr. White Is rather 20 prolonged discussion, would it be incumbent upon us to say 21 since we are attaching no sti,ings to the funds, we nevertheless 22 do not think that project number 28 should be funded under 23 any circumstances? @24 DR. PERRY: I would-be happy to have that included. :e f Repotters, Inc. 25 DR. SC@RLIS: I gather this is Dr. White's J. reaction, Is that correct? 2 'DR. VIHITE: I think it, is. 3 DR. PERRY: A footnote, "ridiculous." 4 DR. WtkYER: All right, additional comments? I gather you are moving then the recommendations of 5 6 SARP. 7 DR. PERRY: (Nods.) So'move. 8 DR. MAYER: All right. Further discussion? 9 All those in favor? 10 (Chorus of "ayes.") 11 Opposed? 12 (No response.) 13 MRS. KYTTLE,: This includes affirmation of the 14 rating? 15 DR. PERRY: I have not had a chance to look at the 16 rating. That was 244, if we look at this on the scale this 17 places them in the two and a-half C category. Unless therets 18 some recommendation for change I would certain reaffirm 19 that rating. 20 DR. MAYER: All right, are -you willing to accept 21 then the ratirg, overall rating granted by SARP? 22 DR. PERRY: I am. 23 DR. IIAYER: I see heads going up and down instead 24 of sideways, so we will assume that we have consensus. :e I Reporters, Inc. 25 I would like to then move to Intermountain, a 0 0 144 Elizabeth. 2 MISS KERR: I would 'again make it clear I have not' 3 visited Intermountain, nor have I before reviewed any of 4 their materials. The secondary reporter is not here, Mr. 5 Spellman. don't know whether he had or not. But I 6 would like to have-- 7 DR. MAYER: Just docunient,in the record that 8 Sister Ann is leaving. 9 MISS KERR: So I would hope that Harold O'Flaherty 10 and Dick Clanton, who are familiar with the area, or any 11 others around this table who have made visits, will feel 12 free to put in anything that they would desire when I 13 get through. 14 The Intermountain Regional Medical Program, the 15 grantee institution is the University of Utah. The Regional 16 Medical Program consists of a geographical area of Utah, 17 parts of Nevada, Montana, Idaho, Wyoming, Colorado, which 18 covers 546,000 miles, and I think we must keep this in mind 19 when we look at the core and a few other things that seem 20 to be quite sizeable. 21 Thei,e are two and aquarter million people, about 22 fifty percent of whom live in urban areas, and therefore 23 the greater portion is.arid, mountainous, sparsely populated. 24 The Intermountain Reg.ional Medical Program is Repotters, Inc. 25 presently in its fifth operational year. It is not within I a triennium. It is presently funded at direct cost of 2 $2,478,645, with an indirect cost of $904,419, which kind 3 of startled me. And they are funded through March 31st of 4 172. 5 This particular anniversary application re-quests 6 continued support for core and 21 projects ongoing, support 7 for initiation of seven new projects, a developmental component, 8 totaling $3,025,219. 9 This anniversary proposal had a staff review on the 10 14th of December and was reviewed by Staff Anniversary Review 11 Panel oh the 20th of December, and recommended approval. 12 As far as the goals, objectives and priorities of 13 this region are concerned, they certainly used the right 14 words, and are therefore in writing compatible with national 15 priorities. But the relationship of.the operational projects 16 to the goals and objectives are rather fuzzy at this time. 17 It appears that the-goals, objectives and 18 priorities speak to such factors as improving health care 19 delivery, accessability, and so forth, but on closer 20 speculation most of the projects are still basically oriented 21 to continuing education. 22 Apparently Intermountain Regional Medical Program 23 continues to demonstrate outstanding progress. Each of the 24 projects that have been funded appear to be accomplish their eporters, Inc. 25 stated objectives. It is felt that the present coordinator, Dr. 2 Satovick, has really done an outstanding job in terms i3f 3 filling the position of the former coordinator and in terms 4 of preserving and even strengthening the autonomy of the 5 Regional Medical Program. There have been a minimum of 6 problems in the transition and in the program as it is ongoing. 7 Apparently they have a very strong staff. There 8 has been considerable improvement in involving the outside 9 organizations in planning and in carrying out program components, 10 I go to the core staff, which.consists of 30 11 people, most of whom are full time, but all of whom are at 12 least 60 percent time or more. Twent,y-four of core staff 13 are men, and their are three Orientals. 14 Then in looking at.RAG, let me say first that RAG 15 consists of 30 people. Now they still have 30 people on 16 their RAG, although the representation has been changed 17 to involve more consumer input, and just a slight token, I 18 should say, of minority representation, in that on the RAG 19 they have at the moment 28 active appointments, 23 of whom 20 are men and two with Spanish surnames. But I think we need 21 to say here that in this particular area we do not find as man3 22 blacks and we do not find as many chicanos, and So forth, so 23 perhaps we have to take this in consideration, too, when we 24 are looking at the minority representation. But it does look -JOR,porters, Inc. 25 a little low. The RAG membership, though it has become more 2 representative of the community at large and is seemingly better 3 informed about the role and the program of the Regional 4 Medical Program, there is still concern that the RAG is not 5 as active as it would like to be seen. The comment here was 6 made that this is duo primarily to the fact that there is 7 difficulty in the RAG membership relating with core staff. 8 This was not enlarged upon, and somebody may want to speak to 9 this. I assumed that because the core is active, is 10 aggressive, is able, that perhaps the RAG sits back and isn't 11 quite as prominent in docisionmaking as perhaps we would like 12 to see them. 13, Tiie education planning'an-I evaluation section 14 appears to have a preat deal of vi sibility. Their major 15 contribution.has been to @sist those people directing .16 education-..I projects, and they he-ve been particularly helpful 17 in the specifications of educational objectives and in 18 evaluating educational programs. 19 However, when we look at the total evaluation 20 program it seems that the majority of their work has been done 21 in the area of educational programs, and little in'total 22 program evaluation. 23 Thcugh they do have some hard data, it appears 24 that the region has established a systematic process for painnin, Repo(ters, Inc. 25 proposals or developing propoqui objectives -- it does not appear that they have used these data to establish their 2 priorities. 3 The region has made considerable progress in the 4 development of subregional centers despite budgetary 5 cutbacks, and they at the present momemt have apparently what 6 individuals they title coordinators in Grand Junction, 7 Colorado, Pocatello, Idaho, and Provo, Utah. In these three 8 areas it is foreseen that there is great potential for area 9 health education center development, and they are looking in. 10 this direction. 11 Apparently the Regional Medical Program is directly 12 involved with many activities of other health planning 1 3 agencies in the region, though it se0iiis that again CHP 1 4 perhaps because of the visibility and the action and the 15 positive movement of the core staff of RMP seems not to be 1 6 as active as one would hope that the CIIP might be. 1 7 The ongoing projects, of which there are 21, two 18 of which are to be phased out at the end of March, are indeed 19 quite categorically oriented and continuing education 20 oriented. 21 The new projects, the seven hew proposed projects 22 seem to fall more in line with the new direction that RMP 23 is taking and is encouraging. 24 In looking at the strengths of this region, ,e I Reporters, Inc. 25 certainly this new coordinator is leaving his mark at the present time, and it is predicted that he will continue to. 2 It is felt he has good administrative ability. It was felt 3 that the core staff is one with.a high level of competency 4 and hard working, with broad vision. 5 The development of subregional centers which may 6 Lead to ABEC'S, at least there is activity out in these 7 centers that is active and has visibility, and this, too, 8 would be considered a strength. 9 The Regional Medical program has had an impact on 10 the improvement uf care of the people in the region. 11 There are a few areas, ',)wever, that need to be strengthened. 12 As I mentioned before, at the present moment it 13 still appears that their overall pr"gram is still pretty 14 much projnct orien'-ed. 15 If some of you caught my early remarks,,you will notc 16 that the indirect costs of $904,4.L9, recognizing that we have 17 nothing to do about this', but it is a sizeable amount of 18 indirect cost, and it is up to sixty some percent -- I have 19 forgotten just the exact amount. 20 Again they need to strengthen the relationships and 21 show them more clearly betwep-n their goals, objectives and 22 priorities as they have writ,".-en them in light of the new 23 mission and what really actually exists at the moment. 24 Evaluation procedures need to be improved in other I Repoftets, Inc. 25 areas than that in which they are doing an acceptable job, I which is the educational evaluation. 2 The region has not done too well to seek out other 3 sources of support for the continuation of its projects. 4 The staff group in its review -- and I concur with 5 this -- is that rather than the 3,025,000 which was requested 6 for the sixth operational year, because of the areals needs to 7 strengthen their activities in those areas identified, and 8 yet to give them an opportunity to do so, it was felt that 9 the funding allocation be kept at the same level as it was 10 last year rather than to increase it to.the $3,025,000, 11 which would remain then 9.t $2,478,650. This was the 12 recommendation of the staff. It also was the recommendation 13 of SA11P, and I would go along with .'iiis. 14 The staf-" review recommended $75,000 for the 15 developmental component. The SARP group -- and this was 16 the only area in which there was any marked difference of 17 opinion relative to their reviews-- the SARP group recommends 18 that this region perhaps if it had more flexibility with more 19 developmental funds could be a little bit more effective 20 in moving ahead to accomplish the strengthening of those areas 21 identified as needing this, and recommended ten percent of 22 the former level of direct fLnding, which comes then to 23 $247,864. 24 As a reviewer with no more familiarity than I Reporters, Inc. 25 have with this area, I agree .-hey have many strengths. I think they have to take a hard look at turninr, the corner 2 further and looking at their projects and relating them 3 to their new priorities. 4 And perhaps I zu-a getting just a little bit squeamish, because as I sit on this committee at times I think -- and 1 5 6 use the word "hard-nosed," but I don't really mean it,that 7 derogatorily, but I think sometimes we get a little generous 8 and then a litttle bit later wonder if we really did the 9 right thing. I 0 So what I am saying is I personally would rather 11 myself recommend the developmental component which would be 12 a part of the total level of funding at $150,000 rather 13 than the $247,00. But I do recommend the developmental 14 component. I recommend it at that level. 1 5 1 would be :glad to hear from the rest of you, and 16 I would be willing to consider changing my mind. 1 7 DR. ILKYL-R: Comments fro,.u staff? 18 VOICE,: I would only comment that the rationale 19 for holding the developmental component at $75,000 was to 20 maintain the existing level across the board. That was the 21 only rationale. .22 MISS KERR: Yes, and I think this is what I 23 assumed. Yet I also gathered from the SARP report that that 24 review group felt that it might-give them opportunity to move e Repofters, Inc. 25 out faster to do things if they had more. I'm sorry. w MRS. KYTTLE: as involved in something 2 else and Missed part of your conversation. Are you on 3 item 2 of the things that require committee action? Says 4 Council approval at a $75,000 limit, staff recommended 5 that that limit be maintained, but the staff anniversary 6 review panel recommended that the allowable ten percent be 7 approved within the 2.4 recommended. Are you saying and 8 1 missed it -- that you do go along with recommendation 9 number two or you do not? 10 DR. MAYER: N , she is saying.-- 11 MISS ]ORR: I compromise. 12 DR. MAYER: She is saying a third proposal, which 13 is to limit it to 150,000. 14 MISS KERR: I believe that the 75,000 may keep 15 them down a little bit too much. I believe the 247,000 is 16 probably more than is necessary to get them to move until 17 such time as we can look at it again. 18 MRS. KYTTLE: Mike Posta, who isn't here today 19, be@ause of illness, and who is chief of the desk under which 20 this region-falls, had a conversation with the region, 21 part of which I participated in, because the region was callirg 22 to ask what latitude it had to redesign and put monies 23 into different places that had generated since this appii- 24 cation had been developed, and part of their concern was that 101 Repoitets, Inc. 25 they had opportunities to move in developmental component kinds of ways. And, curiously, this region has funded a 2 great deal of its development component through grant 3 generated income. One large component that has generated thi3 4 income has generated so much that it is phasing out and it 5 is continuing most of its activities under its own steaii 6 and others. And when that component went they were going 7 to have to redesign some of their inonies.to fund even up 8 to the $75,000 approval that they had been given, because 9 the grant generated income that had substantiated the fund 10 was going around 58-60,000 dollars, 11 Mike Posta tells me that they were talking about 12 activities that would more than double the $58,000 that 13 they had. Now whether they would double the 75,000 I don't 14 know. 15 Did he have a chance to get into that with you, 16 Dick? 17 VOICE: No, he didn't. 18 MRS. KYTTLE: So apparently the region at this time 19 stands ready to use about 125,000. 20 DR. MAYER., Which would be within the $i5o"ooo 21 restraint ttiEt is being suggested. 22 MISS KERR: I guess I had the feeling we have gone 23 on promises so long, but.you know -- I 'm really questioning 24 whether we should do that as much as we have. And this (1-01 Reporteis, Inc. 25 gives them more latitude than they %,ouid have had with the 75vOOO. 2 DR. MAYER: Yes, Leonard. 0 3 DR. SCIIERLIS: I hate to bring up individual 4 projects, but there is a small bookkeeping item of $333,000 5 for multiphasic screening with a comment made in the SARP 6 review that the slowness of the multiphasic screening 7 activity raised doubt about the relationships between the 8 medical school, county and community it was designed to serve, 9 and the IRMP. 10 I was wondering do 'you have any comments upon how 11 well that program is moving or what it means in terms of 12 the present attitudes toward multiphasic screening? I know 13 it is only a small iter, in their to4-al budget. 14 DR. MAYER: Dick, would you care to comment? 15 IM, CLA-MPTON: iLtis was also a concern of staff. 161 DR. SCHERLIS: Could staff tell us a little bit 17 about it? 18 MR. CLAMPTON: The indication is they hope to 19 begin operations in this project as of this month, January 20 of 172. However-- 21 DR. SCHERLIS: This is the third -year, isn't it? 22 DR. MAYE-R: No. 23 @IR. CLAMPTON: Well, they have been toolin,-, up during 24 that period, but they will be going operationally supposedly E! I Reporters, Inc. 25 this month. This has all been a tooling up process. DR. SCIIERLIS: Have they already spent two times @2 333 prior to this third year? What kinds of tools are they 3 tooling up? I don't mean to be facetious on this, but it's 4 obvious that we are talking about an expenditure that is 5 going to run a million dollars by the time it is completed, 6 I hate to hear at this point in time that they are tooling 7 up. 8 ims. KYITLE,: This is part of the Intermountain 9 i)rograxn that has generated carryover every year. They money 10 was awarded, and I believe historically they had troubles 11 with the county on zonir- exceptions, and that carried over 121 one year because they needed to rennovate and werenl!t very 13 successful with exceptions that they needed. 14 T know tie chart- show that monie s were awarded, bul 15 they were not expended. They were carried over. Some of 16 the money reinvested in this pro4ect is the same money 17 that was awarded the year before. Not all; some. 18 DR. SCHERLIS: I would suggest as a logistical 19 pi y that this be a device that every RMP follow; namely, 20 to have an expensive project funded, because it then gives 21 a utilizable source of funds to be used for developmental 22 component. 23 1 MRS. KYTRLE: I think it was a model cities joint 24 endeavor. le Oal Repoiteis, Inc. 25 MR. CHA@IBLISS: Yes, I think the committee should 156 I know that, as Mrs. K-yttle points out, this was a model cities 2 project. 3 We have undergone some concern about this project 4 not getting movin- before now. It relates very directly 5 to the same kind of problem that was encountered at Meharry 6 of muitiphasic screening, And here again, if you recall, 7 there is a policy determination on the multiph@-ic screening 8 to see how they are going to move before we get much further 9 into this, and we are beginning, I believe, to see some of 10 these answers fail out now. 11 DR. MAYER: A you recall, Leonard, when we approved 121 that one we approved it with really that thought in mind, 13 and it looked like one of the better multiphasic screening 14 Proposals that we l.ad, and 4t also was involved in a 15, joint effort with model cities in terms of the population 16 served, et cetera, et cetera. But -your point is well taken 17 about the built in developmental component. 18 DR. SCHERLIS: I am just wondering what should we 19 do ".t this point in time about the third year coming up, let 20 it go at 333? What was SARP's reaction to this? Aside from 21 having some negative gut reaction, what logistical-- 22 IIR. CHAIFBLISS: MAybe I can share our reaction with 23 you. That sentence that you read does encapsulate our 24 feeling here, and we raised a-further policy issue about ORepotteis, Inc. 25 the interface between technology and service. That wELs 157 encompassed in that discussion. 2 DR. SCliERLIS: I guess the real meaning of my 3 question more directly is do you translate that into 'your 4 final dollar and cents recommendation for the region. Was 5 that part of -your consideration or not? Or did ou just 6 say we will keep that at 333,000? 1 was curious. 7 MRS. ICYTTLE: With a funding level recommended of 8 2.4 something is going to have io give. I don't know whether 9 it will give out of muitiph,,tsic screening or not. 10 gative to decide, MISS YXRR: This is their prero 11 isn't it? 121 DR. BESS: But I wonder if something shouldn't be said about this in the advice letter, because again if 14 .:rou loob, at everything OISL this seems to be funded 15 disproportionately high. 16 DR. AIAYEil: The question that I had is what are 17 the implications of the recommendation, and I am asking it is vis-a-vis the comments tiiat Dr. Margulies made yesterday 19 relative to potential add on dollars going in. If we took 20 no action the region's request for the 06 -year -- well, the 21 region's approved level for -'@he 06 -year by Council as it now 22 exists on a previous action in the triennium was 2,687,000, 23 and we are now recommending 2,478,000 as a funding level. 24 What does that mean in terms of recommendation that goes to @-01 Reportets, Inc. 25 Council, and is this really a suggestion that you lower the .L.JO I previous Council approval of the 06 year by approximately 2 200,000 or not? I just need to understand the implications 3 of the motion. 4 MRS. KYTTLE: It Is afunding level, not an approved 5 level that we are making, 6 DR. MAYER: All right, fine. Did you hear the 7 response, that it was a funding level we are talking about 8 and not-- 9 DR. BESSON: I think the point of this question .10 really revolves about how these figures.were arrived at, 11 and it really takes a little bit of scrutiny to determine 121 how 3.025 is cut down to 2.478. But it seems to me that that figure is arrived at not arbitrarily, but by looking over 14 each individual pr@ject an-' saying this is not appropriate 15 and this is.. 16 Am I incorrect in that, Lorraine? 17 MRS. KYTTLE: Well, I'm not chairman of SARP. I'm 18 Exec Sec of SARP, but this is how I recz@,11 the figLre was 19 ar4ived at. Some calculations were instituted, and when you 20 started adding this and subtracting that the members of SARP 21 concluded finally that if you sent them the message that 22 two projects that have been criticized before stand criticized 23 again, and if you send them the message that they have turned 24 off one that we wanted turned off, and if you send them the :e 1 Repotters, Inc. 25 message that some of the new activities that they are I proposing are looked upon much more favorably than some 2 of the continuations like, I believe it was project i8, and 3 say you get the same amount of-money next-year as you had 4 last year, and within that framework to make your decisions, 5 that they felt they were coming to about the same amount 6 of money. 7 DR. BESSON: Well, it would be very heopful if 8 we could have the basis on which SARP arrives at its funding 9 level because this is really the way we operate here, too. 10 We start with a number and then add and subtract to it. Now 11 as I look over the ite,q requiring committee action, I see 12 that there are suggestions based on approval or disapproval 13 of individual projects, and as I hove looked over some of 14 the now prnjGcts ',hat you gay are more in keeping with 15 the new missions I may disagree with some of those. But 161 I think in the light of the question raised about multi- 17 'phasic screening it would be important for review committee 18 to know whether that was "deleted" or whether that was 19 a!-ov!ed to stand. 20 MR. CHfilIBLISS: It was allowed to stand. 21 DR. BESSON: Well, then it might be appropriate for 22 us to know a little bit morG detail as to how SARP arrived 23 at its funding level recommended. Maybe that's a loss to 24 us now, but in the future I think it would be helpful. I Reporters, Inc. 25 DR. MAYER: I thini, the point you are making is a valid one, Jerry, and I would like to suggest that it really 2 would be helpful to this committee that when SARP does 3 arrive at recommendations concerning funding level that 4 you know, we went through this process just now, we have been 5 going through that process for six years -iow, and we would 6 hope that something akin to -- if SARP is going to replace 7 our activities, that something akin to the procedures 8 being used here are also being used there, and that that 9 information be brought to us. 10 Yes, Harold, do 'you want to comment? 11 MR. O'FLAHERTY: I was going to say in response to 12 the question there has been a concern, particularly over 13 the last year, with the Intermountain R@IP that they ave 14 shown a very lack of being able to make any hard funding 15 decisions. A lot of their ideas --.as has been pointed out, 16 they have come up with new ideas that are valid, they have 17 a lot of palatability in the region, but nevertheless we have 18 activities that have been going on out there for up to five 19 years, and we felt that to increase the funding level over 20 this past year would in some ways put a commendation to 21 this process. 22 The group did not feel that they were ready, the 23 Regional Advisory Group was ready to make some of these hard 24 decisions that had to be made in this region and to turn off e -01 Reporters, Inc. 25 some of these old activities that should have demonstrated their utility or nonutility to the s stem at this juncture. y 2 So we felt it would be a disservice almost to aggrandize 3 them in this capacity to add to the past kear's level. 4 DR. NIAYE, R: I think one can just look at the fact 5 that the dollars are precisely the same as last year and 6 assume that. I think the issue is we would hope that SARP 7 is arriving at those conclusions on a more exploicit basis 8 by looking at projects and finding out what projects they 9 think ought to be phased out, et cetera, et cetera, and then 10 adding on those that need to be approved, and that level 11 may not be 2.4, that level might bei.9 million or 2.39 12 million or some other such figure. And it is that explicit- 13 ness that I think we would like to see incorporated into the 14 SARP process as well as our own. 15 Is that, Jerry, adequate paraphrasing? 16 DR. BESSON: Well, I know it is incorporated in 17 SARP thinking, but I think it should be made available 18 to review committee. I'm asking that it be made explicit. 19 DR. MAYER: Well, I was taking it one step further, 20 assuming that the level came out exactly right, they didn't 21 go through the process that we have gone through. Now 22 that's just putting two and two together. That may not be 23 right. So I think there's a second component to it, 24 not only should we know about it, we think it should be done. Reporters, Inc. 25 Yes, Elizabeth. I MISS KERR: I Would like to also make two more 2 comments. 3 In looking at the mean weights given by the review 4 panel they are strikingly similar to what I would have felt 5 viDs reasonable, and you all can make your own decisions, 6 having read the material. But I think they point out very well 7 where the weaknesses are. And it shows it a little bit above 8 satisfactory, and that's about where I would, as a reviewer 9 on paper, put it. 10 I also want to make one other.comment; since this 11 is our first go through after having a SARP procedure, to 12 me it was very helpful. I do agree with what you are saying, 13 however, Jerry, that some of these details maybe if shared 14 with us Would be good. But I do want to say.it does appear 15 to me that the SARP procedure is helpful to the reviewers. 16 DR. MAYER: All right, further comments? 17 DR. THURMP.N: I second the motion for 150,000. 18 DR. MAYER: So what we are suggesting is the SARP 19 recommendations with the exception that instead of not to 20 exceed ten percent under item 2 of the recommendation we 21 are saying not to exceed $150,000 in the 05 year vis-a-vis 22 the developmental component. 23 All right, further comnietits? 24 Yes, Jerry. :e I Repottets, Inc. 25 DR. BESSON:. I also Wonder a little bit about the Iva letters of transmittal of our decisions here. if the area is 2 to have a litie bit of a sense of what the messages arb@that 3 we arc transmitting they have to be something less than 4 cryptic, and I think they may be quite cryptic if we just give 5 them a number without backing up how we arrived at the number. 6 The region may take refuge in considering that these ar e just 7 funding constraints because RMPS doesn't have enough money this 8 year and say "well, we are doing exactly what's expected of us, 9 and if only R!,APS had a little more money we could have some 10 more," but that may not be what .,,e intend. 11 Is there any way that review committee can have some 12 feedback as to exactly what's told the region after we come 13 to sort of very thearia.L decision here and say well, somebody 14 is going to let the region know what the messages are 15 that we are transmitting. 16 MRS. KYITLE: Dr. Besson, we had copies of all the 17 advice letters from the last review cycle ready, and I had hopeJ 18 we would got them ready to give them to you today, and it is only that the same people are involved in ail of this are 20 the same people that were invol ved in all that that we didn't 21 get them to you. If you don't catch a very fast train going 22 home it will be there waiting for-you, copies of the advice 23 letters that generated from the last cycle. 24 MR. CffiUfl3LISS: If I may add on to that, that is 'Cleat Repofteis, Inc. 25 now a matter of policy, that the members of the Advisory 4 C@uncil, the 'members of the site visit team,- and the 2 consultants, along with the chairman of the RAG and the 3 granl-lee institution, will get copies of the post Council advice 4 letters. So this information will be widely disseminated. 5 DR. BESSON: Will those letters of advice 6 incorporate the kinds of specific comments that we make about 7 projects, that project number 28 for Susquehanna Valley 8 is ridiculous? 9 MR. CHA-@IBLISS: Yes, indeed, 10 DR. BESSON: I mean maybe dressed up a little bit. 11 MR. CHMU3LISS: Vie won't say it in that way, but 12 we will make it very clear to them, your concerns. 13 DR. MAYER: It will also say if,you have any 14 questions about what that word means just write Dr. Philip 15 White, Marquette University. 16 (Laughter.) 17 MISS KERR: One of-the things we haven't discussed 18 at ail is the mini'report of the mini-SARP review committee 19 on'renal disease application which is incorporated in the 20 total amount, but I don't want to lot it pass by without any 21 reference to it. And that is that on 25B you will notice 22 in the peach colored sheets -- 25A, rather, is control of chroii 23 renal disease, and the part of this in the application is an 24 ongoing program, but the committee wished to point out Reporters, Inc. 25 it says "the directions the regions appears to be going I appear to be nonproductive, and would give a low rating 2 if so asked regarding this activit,y.@, Furthermore, the' 0 3 progress report is not satisfactory because of its incomplete- 0 4 ness and brevity. Relative to 25B in the ALG portion, it 5 would have to be deferred pending the R@@o policy decision on 6 this. 7 Relative to section 25B, again it indicates that 8 there has been some new information fed into RMPS as of 9 December 9th relative to the activities for the renal control, 10 and I do not have this information. 11 @IR. GROSS: The new information related only to 12 supplemental activities, namely, 25B. It was basically 13 a more detailed description of what they were applying for 14 and the reasons for it. If you would like, at the present timD 15 I can give you what my reactions were as a staff reviewer 16 in more detail of the supplemental activity, 17 My recommendations were that this not be approved 18 as.well because of the following reasons. First of all, it 19 appeared -- first of all, what was requested was the funds 20 for hiring an organ profusion technician as well as an organ 21 procurement technician, and thirdly, the ALG aspects of 22 the program. The ALG might be mentioned first because the 23 decision there is a little simpler. R.@IPS has yet to make'a 24 policy decision on that. I think any decision regarding e I Repotters, Inc. 25 funding of that has to be deferred. The objections that I had to the first two portions, 2 tiD profusion technician and the organ procurement technician, 3 were not that such a need is probably not justified in an 4 absolute sense, but that poor planning I think was 5 demonstrated in the fact that these profusion machines 6 had already been purchased, and it has been clearly 7 demonstrated that the ancillary personnel for such a profusion 8 approach to organ procurement are also a necessary part 9 and should have been employed initially, and why they would 10 have purchased the machine and now are.requesting the 1 1 necessar,%, personnel is @yond me, 12 A.nd secondly, that this sort of piecemeal support of a program "- I mean asking for supplemental activity 14 and just v,,intihg, you irnol- a couple of desks sort of thing, c 15 coupie of technicians here and there. without clear evidence 16 of how they are going to be utilized, was lacking. 17 Thirdly, it has been demonstrated in many areas 18 that third party support can be generated for organ 19 procurement if a single cost isid3ntified. Many insurance 20 carriers are now in several areas willing to pick up the tn-b. 21 for this. The precedent haE- been set. So I am not sure 22 the actual fiscal need for this is there. 23 And fourthly, in their application they did not 24 make any mention of why RMPS-specificall-y was needed for C,Oal Repottets, Inc. 2 5 support of these individuals. In other words, why other I so of funding, of which there are many potential ones, urces 2 weren't available. 3 So for all of these reasons, pririarily poor planning 4 reasons and poor justification reasons, I didn't think that 5 25B was worthy of approval. 6 DR. IDAYER: Thank you, Dr. Gross.. 7 MISS KERR: Thank you, This is helpful. I don't 8 think this alters the level of funding we are recommending, bu,: 9 1 am wondering if we don't want to in the advice letter, or 10 least include in this some of our discussion relative to this. 11 DR. hlAYER: lYell, I assume that -- my assumption 12 is that advice letter comes not only from information surfaced 13 here, but in these instances by SARP and elsewhere. 14 Yeso Joe. 15 DR. HESS: I had a question that may have relevance 16 for the advice letter. Did you a-i you reviewed the 17 application have the feeling that-they are really reaching 18 out into some of the far areas away from Salt Lake City 19 to address some of the problems in Wyoming, Montana, et 20 cetera? The majority of these projects are University of 21 Utah based and Salt Lake City focused, many of them are, .22 although they have established some regional off' ently ices appar 23 in trio or three other locations-- 24 MISS KERR: Urban areLqs again. ,e 1 Repottets, Inc. 25 DR. HESS: Yes. But in this area some of the real 168 1 problenrare rural problems. And my question is are they 2 really making an honest to good ness attempt to cover the 3 problems in the total region for which they are responsible. 4 MISS ICERR: If -you are asking for my reaction, I 5 feel they are not getting to the rural areas. There is not 6 the evidence that they are. 7 DR. HESS: What aboutthe staff reviewers? 8 DR. @IAYER: Someone from staff want to make a 9 comment? 10 The question is to what degree are they relating 11 to the rural component of Intermountain region. 12 MR. CHk@.U3LISS: Out of SARP came the view that you 13 hold, that there needs to be much more outreac n erms 14 of their program. 15 DR. HESS: If that is indeed true I would suggest 16 a recommendation to that effect be incorporated in the 17 advice letter. 18 DR. MAYER: Ali right, everyone understand the 19 motion? 20 All those in favor? 21 (Chorus of "ayes.") 22 Opposed? 23 (No response.) 24 Thank you, Elizabeth. I Repoitets, Inc. 25 We move on then to Alabama. es I DR. BESSON: We should be able to complete Alaban-a 2 in five minutes. it doesn't require any committee action. 3 DR. MAYER: It didn't take the big eight much longei 4 either, Jerry. 5 (Laughter.) 6 DR. BESSON: But I will just give the committee 7 a bird's eye view of the Alaba-sna program, and I am interested 8 in knowing why SARP felt that -- it took the option that' 9 this didn't review review committee action and others in 10 the same general, category did, not that I doh't share I I SARP's view, but in jupt elucidating the modus operandi of 12 Anniversary Review CoAnmittee. 13 '.ehis is Alabamals first ..iniversary application in 14 the triennium.. Tii region is requesting some two million. The Council has previously approved.at the time of the trienn' 15 lull 16 application for the upcoming year 1.6 million, and the Staff 17 Anniversary Review Panel recommends 1.15 million. 18 1 won't detail the -- oh, the 1.15 million is made 19 up,-- the request is made up of continuation of core for 20 the fourth year, six ongoing projects, two approved and 21 unfunded projects, and eight new unfunded projects. They 22 are not new, they had previously been approved. 23 Tha major concern that staff has with-the Alabama 24 region is that in spite of the fact that there is a strong @A*Reportefs, Inc. 25 RAG and that their priorities are well ordered, they have great difficulty in relating projects to priorities, and 2 the director feels that a staff tactical review of the 3 Alabama region is necessary. 4 In looking over the program I concur with SPRP's 5 recommendation that the committee has no need for action. 6 DR. MAYER: Further comments from those that 7 participated in the SARP review on the staff? 8 Anyone want to coriment on Dr. Margulies' comments, 9 which was simply that that letter of advice was very 10 important and that some of these issues needed to get incorporated in it, perhaps even some direct staff discussion. 12 Comments from the committee? 13 Jerry, would you phrase your question again for 14 staff, or I can try.to paraphrase it. 15 DR. BVSSON: I have no question. 16 DR. @LKYER: Well, I thought the question -- at least 17 I heard you ask a question which said-- 18 DR. BESSON: Oh, yes, the question I have is and 19 this came up before -- whether staff could outline for 20 review committee exactly what its modus operandi is 21 vis-a-vis anniversary review, which ones they choose the 22 option to present to review committee and which not. 23 pect to procedures any MRS. KYITI;E: With res 24 anniversary in its triennium need only .get Council approval I Repoiters, Inc. 25 by regulation. By agreement -- and Dr. Pahl outlined this I at the last committee -- anniversaries within the triennium 2 that are going on their way to Council still stop off'at 3 committee prior to going to Council , so that if committee 4 has something before it for information only that nevertheless 5 jars it, it can make noises at that time. 6 With respect to Alabama, though, Dr. Besson, the secretary of SARP asked the specific question on Alabama 8 as to whether SARP would want to refer Alabama to committee 9 for action, and SARP decided it did not. 10 Anniversaries prior to the triennium do come to comiii 11 for action, as our agreement that Dr. Pahi outlined. This 12 is an anniversary within a triennium, and it comes to you as 13 information on its way to Council. 14 DR. MAYER: I gather they -- perhaps need to clarifl, 15 the question of what Jerry was saying, was on what basis do 16 you make this decision that you pop some here for action 17 and some for information. 18 TARS. KYTTLE: Changes in program direction or 19 methods of operation, such as what brings Northiands to -you 20 for action even though it's an anniversary within a 21 triennium; failures in staff's view to meet the standards 22 that the region set for itself in the first place, which 23 brought Metro D. C. to you with a site visit. Those are the. 24 two primary reasons. ice*,,l Reporters, Inc. , 25 im. CHAIMLISS: Or they are askingfor funds in I addition to-- 2 MRS. KYTTLE: They go to Council, by regulation stop 3 off at committee. 4 DR. MAYER: You mean those that are requesting 5 no, wait a minute. I think what Mr. Chambiiss was suggesting 6 was that those that rere asking for dollars in the anniversary 7 within the triennium, for dollars above those previously 8 approved by Council, don't those come here? 9 MRS. KYTTLE: No, sir. An anniversary within its 10 triennium that doesn't ask for any more money than its 11 approved tevei Council h-s delegated to staff. 12 DR. MAYER: No, you missed the question. The 13 question was those that are a--,king f-,r more money than was 14 approved b-v Council. do thev not come here? 15 MRS. KYTTLE: Witnin a triennium? 16 i)R. MAYER: Within a triennium an anniversary request 17 that asks for more dollars than approved by Council. 18 VOICE: Funded level or Council approved level? 19 DR. MAYER: Council approved level. 20 MRS. KYTTLE: No, not within the triennium. 21 DR. MAYER- Well, by George, I think it ought to. 22 You R-now, if I were a Council member I would sure want the 23 advice of this committee on those. 24 DR. BESSON: It would be nice if we could have these Reporters, Inc. 25 all spelled out for our next,review committee meeting so we J. f 4 -y what we are sup would know exacti posed to do. @IRS. KYTTIX,: They are spelled out insofar @C, 2 3 Council is concerned. Council has delegated to the Director 4 to make continuation awards within the triennium and just 5 advise Council unless the region asks for more money than its 6 approved level. 7 DR. BESSON: lYell, that's what he just described. 8 MRS. KYTTLE: Yes. Now in setting up the procedures tc 9 operate under that delegation and this is what I understood 10 Dr. Pahl to present to committee last time -- anniversaries 11 prior to the triennium, in an effort to keep your workload 12 on trienniums the point of action primarily, under Councills j3 delegation we would deal only N@ith Council and advise committee 14 after the fact of what Council had recommended within the 15 triennium. It was at the last committee meeting that 16 Dr. Pahl agreed to advise you prior to the Council rather than 17 after the Council. 18 Did I get that wrong? 19 IIR. CHA1,113LISS: No, I think that-- 20 DR . 14AYER: You got that right, but I can assure 21 you that if Dr. Pahl suggested that those that were above 22 the funding level already approved by this committee and 23 Council were going to pass by this committee without even a 24 blip I would have come out of my'seat. So I suspect he e-01 Reporters, Inc. 25 didn't communicate that to us, or I was gathering wool when he did. And I think that's an issue that needs to be 2 clarified because I think it's important. 3 DR. THURI,,IAII: Bill, he did sp--ak to that when those- 4 of us who wer new were indoctrinated. He said exactly as 5 Mrs. Kyttle has said, but we did not know enough to say anythinr 6 back. I am speaking of those of us who were new to this 7 committee. 8 DR. MAYER: I see. 9 DR. THIJRIIAN: Because as she has phrased it is 10 exactly as it was phrased in that indoctrination session, 11 and Dr. Pahi conducted that. 12 DR. MAYER: I guess then what I would like to 13 request, if the committee concurs, that further staff dis- 14 cussion occur about that one particular issue, because 15 otherwise, 'you know, a region could,request two mil in the 16 second year of its thing and it wouldn't fly by here at all. 17 You know. And I suspect that -you might like to know how 18 that two mil is being spent. 19 okay, further comments on Alabama? 20 New Jersey. Dorothy. 21 MISS ANDERSON: Yes, New Jersey -- this again is 22 for your information. No action is required. 23 This is a review that was done by staff. I -was not 24 there, and so I am just reporting to you the result of their kc Olal Reporters, Inc. 25 findings. r NEW JERSEY so #a I Apparently this programi triennial review came 2 through with awards for funding for only one year, an@ someho,@. 3 the second and third year fundings were overlooked. So 4 consequently this is the m ain purpose for it coming in at 5 this time, 6 In reviewing the original request for this program 7 1 was very much impressed upon the action within this RAG 8 organization. The New Jersey RAG is really a group of core 9 people and active committee members who are involved in 10 changing and improving the health care delivery system in their I I community. 12 New Jersey, as you know, is one of the most defisely l@ populated states in the United Sta@t.@s, and it faces 14 intensification of the pro-lenis that other urban areas have. 15 Their greatest problem they found was basic health 16 care, and in recognizing this they designed their goals in 17 @this direction. 18 Their first priority of the region revolves around 19 im-roving accessibility, quality, quantity of health services 20 for the urban disadvantaged. 21 You will be interested to know that 80 percent of 22 the money requested in the past has gone for community 23 programs. 24 For two years the urban health component of this I Reporteis, Inc. 25 RMP has had staff active in the model city programs in the I Siate, and the accomplishment-sof the urban health coordinators 2 are impressive. I think there'.s 17 urban health coordinators 3 at 17 different locations. 4 A hospital based family he.alth service in 5 Now Brunswick has been developed, and a consumer health radio 6 series has begun this 'year. It was interesting they surviewed 7 and found that people really learn more from the radio than 8 they do from the T.V., and the people in the underserved areas 9 had their radios on most of the time. 10 Next year they would like .to see the initiation of 11 a comprehensive family health service in Newark, and a 12 community health improvement project. 13 ,this latter activity is L7questing $50,000 to 14 $100,000 to be divided among the 17 cooperating cities on 15 a matching basis according to size,.need, and available 16 resources to support the development of primary ambulatory cars 17 centers. 18 What's interesting is the fact that this RNIP is 19 reA.Ily working with many of the local, federal and state 20 agencies in cooperation in developing these various programs 21 and resources. 22 Now in reviewing this in the past the staff was 23 cautious abcut their approach, and thought maybe tLey should 24 try it in only one or two cities. But because of the good ce I Reporters, Inc. 25 background activity that has taken place and enthusiasm of I I the staff they feel like they don't hesitate to recommend 2 the go signal for all 17 locations that are being discussed. 3 The core staff is made up of 15 people and six 4 clerks, but the project core has 53 people and 40 clerks. 5 Some of the concerns the panel had were, one, 6 what is the rationale behind assigning project status to 71 the urban health component rather than including it as part 8 of core where this function would seem to lie logically. 9 The staff also felt that in a project ac- limited, and whereby 10 if you had core activities it could go.on for a much longer 11 period of time, and I think many other RIIP's are u4..-ilizing 12 their core in % smiliar method. 13 It was noticed with some condern that this massive 14 effort in urban health has an entirely white professional 15 core staff.- And I could not find any indication of any plans 16 for hiring minority members. On the urban health component st 17 there are three blacks and three Spanish surname professional 18 personnel. 19 The New Jersey program was commended by the review 20 panel for the success it has shown in garnering funds from 21 other sources, particularly the large amounts of federal and 22 state money which had been funneled into the model cities 23 area and the considerable support which had been received from 24 the State Health Department. :e I Reporters, Inc. 25 Their RAG -- as I go down the line, their RAG and I their grantee organization are identical bodies, and it 2 seemed like this might be a possible conflict, but thdy 3 assured the staff there is no conflict of interest in this 4 set-up. 5 There are 27 members of RAG, and five of these 6 members are black minority members. 7 The overall panel assessment of the New Jersey 8 Regional Iledical Program was that it is an excellent program 9 which has become a potent force in medicine in New Jersey. 10 The goals and activities of the program are geared to the 11 unique requirements of the area, with a primary emphasis on 12 improving health care for the urban disadvantaged. There 13 are too@ numerous less expensive efforts directed toward 14 increasing the effectiveness and efficiency of existing 15 facilities and services and increasing the skills and 16 knowledge of health practitioners. 17 They had a program that I was looking at in more 18 detail which I thought might be combined, the one -- oh. dear 19 where is that -- one in regard to medical audit in hospitals, 20 and they discussed the possibility of expanding this, and 21 1 think it would be very worth while to expand it beyond 22 just the medical physician component, but also to the other 23 allied health members who are involved in medical care. 24 In terms of arriving at reasonable funding level ce I Repotteis, Inc. 25 for the next -year based on the success of the program to dat the b for the future, the o and right prospects it holds 2 panel thought that the current level of $1,087,904 was 3 entirely inadequate, and they are consequently recommending 4 $2,990,000 for this, the third and fourth year. 5 DR. MAYER: Ail right, lot me see if I am clear. 1 guess I need to have a better feeling. In other words, this 7 committee recommended, I gather, with Council approval, that 8 they be funded in the 03 year, the first -year of their 9 triennium, for 2.9 million. 10 MISS AlxTp-,RSON: Yes. 11 MRS. KYTTLE: 2.99. 12 DR. MAYER: 2.99? That was our previous 13 recommendation, too? All right. And then by a-decrea.-,e in 14 the funding process by staff or some other device was 15 cut back to the million 225? 16 Eileen, you want to tell us -- you know, I'm just 17 trying what the action that we are saying on the surface 18 would look like we are saying okay, SARP has just said throw 19 in another 1.7 mil, and that, -you know, on the surface gives 20 me a little trouble., so I gather the story has to be a little 21 more complicated than that. 22 VOICE: There are two problems. When the region 23 came in with the triennial application 'it was at a point where 24 core was in its third year of continuation, had one year's Ile ral Repottets, Inc. 25 commitment remaining. And the region as well requested only on -year for its developmental component. And we weren't operating then nearly as cleverly as we are now, and the @2 region didn't picli it up either. So when the committee made 3 a recommendation as to an approved level core, the developmental 4 5 component, and certain continuing parts of the program were nol 6 taken into consideration in arriving at a dollar amount 7 for the second and third years of the triennium. Now for the 03 year, although the committee recommoid. 8 e,l 2.99 million the region was actually funded at just a 9 10 couple of dollars over a million. So what SARP 49 suggesting is that Council restore for 12 the second and third years of the triennium the approved J'3 level that was given for the first -,)ar, the rationale being 14 that that is the irtent of the previous reviewers, and 15 recomrionding as well that the region be given lots of extra 16 money in terms of actual funding, actually 2.9 million which 17 is what is requested in the application. 18 One thin- I did want to comment when -you were describing the community health improvement pro-ram, that 19 request -- the entire request is for $900,000. It is to be 20 21 utilized in lumps of betweeen $50,000 and $100,000 to each 22 of 17 model Cities. But the total request is for $900,000. 23 DR. MP.YER: Yes, Len. 24 DR. SCIIERLIS: Ilow did the decrease from 2.9 to e I Reoofters, Inc. 25 1.2 actually take place. I'm curious. That's a tremendous A- W.L 1 drop, and-- 2 MRS. SILSBEE:That.was the level at which they were, 3 and there was no more money; had to keep it at the'same level 4 and actually cut it back. 5 DR. SCHERLIS: In other words, that was just 6 keeping it where they were. Funds were not available at 7 that time. 8 DR., MAYER: I gather they came through here with 9 a triennial request before we Nvere establishing prior -y 10 ranking. 11 VOICE: Yes. 12 DR. MAYER:' What is the impression of staff, going 13 back through our minutes, of Nvb.ere we would have put that, 14 A, B or C? 15 Mi KRALEI@SKI: I wonder if I might comment on this 16 since I Site visited last time. 17 DR. MAYER: Ali right. 18 DR. KRAIXVISKI: I think it is a very good program. 19 Th@re is some of the best leadership there that I have seen 20 in a corporation. Dr. Florin was a good guy. Dr. Hartman 21 is a good administrator, and he really keeps track of what's 22 going on in that place. So I think, from my estimation at .23 least, we probably would have rated this thing one of the 24 top progra.,as. A rat Reporters, tn c. 25 Now on this funding, though, it seems to me that they were operating at a higher level than that 1.1 or 2 or 2 whatever it was, and I suspect..that that was a cutbacli, as 3 a matter of fact, in their operational level, because as 4 I recall, I don't believe that our recommended level of 5 funding was twice as much as what they were getting at the 6 present time, going from one to three. I might be wrong on 7 that. 8 MRS. SILSBEE: it was 1.3. 9 DR. KRALEWSKR: They had a lot of programs going 10 when I visited them, and particularly a lot of exciting 11 programs going with the core city. They were making a good 12 contribution, there was no question about it. 13 They had a numl3er of good staff people on board, 14 and I' don It know if they still have them or not. Maybe becaut; 3 15 of the cutback they have had to-- 16 DR. HESS: According to the slieet here, when you 17 visited them, John, they were operating their funding 18 ..Level at 1.3, and then they were cut back to 1.2 for 19 budgetary reasons. 20 VOICE: The cut brought them back to about 21 $1,087,000, and then at the end of f@scai '7i we gave them a 22 supplemental award to bring them up to 1.2. 23 DR. MAYER: lVe actually recommended a JL20 percent 24 increase? ce I Repoiters, tnc. 25 DR. SCIIERLIS: You must be a good salesman. DR. MAYER: You're powerful, John. 2 (laughter.) 3 DR. KRALEIYSICI: As I said, I don't recall recommend- 4 ing an increase of that magnitude, but perhaps we did. But 5 the impressions that I again give to the group were that 6 we did rate the program. very highly. They really had been 7 able to switch over to the new RIVIP mission very rapidly; 8 they had a good staff, they were involved in the real gut 9 issues of that region, and they were producing. And so we 10 recormeded a substantial incr case, and.j gather that the 11 group here -- I don't remember just all the discussion that 12 took place, but anyway it was roughly-- 13 DR. SCHERLIS: I was on a site visit with Dr. Florin 14 and I was very impressed with his ability. 15 DR. MAYER: The rating by. SARP at least is 4i2o 16 which is off of the scale, you know, of the sheet here. 17 So all right, I feel better about all that. 18 Other comments that anyone has? 19 DR. KRALEUSKI: If we are going to give them roughi5 20 a million nine -- a million seven increase? 21 VOICE: That's what we recommended. 22 DR. KRALEIVSKI: You have been in touch with them, 23 I am sure, in between. Are they capa@le of handling that 24 influx of money all of a sudden? What I am worried about is I Reporters, Inc. 25 if they have lost some of their staff-- I ney, VOICE: No, the largest chunk of this mo 2 percent-- 3 DR . ICR.'KLE I'@ K IThe model cities? 4 VOICE: Eighty pe rcent of the request is for urban 5 health, and they do have lots of people, 6 DR. KRALEWSKI: Do they still have those individuals 7 on their staff yet, the guys who were operating in the model 8 cities program and were funded part by-- 9 VOICE: Yes. 10 MRS. SILSBEE: They also have some that were used as 11 staff the+ were put in '.; the state. 12 DR. SCHERLIS: I think it should be emphasized that I this was the level of your original request anyway. 14 D-.t. MAYEI..: Sorr', Len, I missed that. 15 DR.' SCHERLIS: It was the level of the original 16 request of the sit3 visit and of this committee, is that 17 right. 18 DR. KRALEWSKI: That's right. But my question is 19 whE.her it's the same organization now that it was during that 20 visit. 21 DR. SCHERLIS: And they reassure us that it is. 22 tM. CHP2,IBLISS: Doctor, you raised tha question 23 about whether that staff that has been working i'6 urban health 24 is still there, and I think the answer is yes. "real Reporters, Inc. 25 Furthermore, that staff, as you probably recognize I it's called an urban state. The whole state itself is just 2 like one big -- I won't say a ghetto, but it's just onb big 3 rundown state. And the idea coming out of the staff was to 4 the effect that that urban core group would be made a part 5 of the core, and that they would no longer be supported under 6 a project as they had been, and that was one of the 7 recommendations coming out of SARP. 8 DR. MAYER: okay, further comments relative to 9 'Llow Jersey? 10 All right, I will move on then to Notthiands RMP. 11 The Northiands RIIP is r euthemism for the state of Minnesota. 12 It started out originally as being more than that, but 13 they finally retracted it back and dut it in the state 14 border, with 3.8 million people. It has been operational 15 since March of 1969. 16 The triennium was approved at our last January, 17 -February review cycle a year ago, I participated in the 18 triennial review rite visit along with Al Putinan in December 19 of'1970, just a little over a year ago. There has been no 20 site visit since that point in time, but there has been a 21 management assessment team from staff in there within the last 22 month or so. 23 We approved, as well as did Council, the trienn ial 24 application and the developmental component, with a budget ,4b, Reporters, Inc. 25 of $1,157,000. They were approved py the Council in the 04 m I 0 0 0 year, that is this next coming year, which is the second 2 year of the triennium which we are reviewing, a level of 3 $ip45OpOOO, with committed funds for that year the same as 4 the existing year, that is $1,157,000. 5 They are requesting in the 04 year, that is this 6 coming year or the second -year of the triennium, too million 7 on in direct cost, including 309,000 for a kidney project, or 8 roughly a million eight plus the kidney project, that million 9 3ight being roughly about 700,000 above the current funding 10 level. 11 From an orga,-4.zational standpoint this is one of 12 the regions that has a board of trustees and a RAG which l@ have had pro brews initially on who a on first, the'.board of 14 trustees or the Ri'-G. It 1-ioked like we were resolving When 15 we were there in favor of the RAG assuming the responsibility. 16 The subsequent year seems to have proved this out in 17 terms of responsibility, and they now are in the process of 18 merging the two groups, with a meeting at the end of this 19 me-Ith to finalize that. 20 As far as the cccxdinator and staff, we were 21 impressed when we were out there with Dr. Winston Miller, 22 the coordinator, and his ke), staff. They were very strong 23 and effective. And we v,,ere particularly impressed with the 24 system that they had evolved.of monitoring the achievement of ;,*,I Reportets, Inc. 25 staff and accounting for the tine and expenditure of staff in light of preestablished goals for each of those individual,,. 2 That is one of the mos.t effective management tools that 3 I have seen actually functioning for quite a while. 4 As far as their goals and priorities, one of the 5 key issues when we were out there expressed by the tiorthiands 6 staff and the RAG is the difficulty they may have in 7 turning this region around towards now goals in light o 8 the existing commitment they had for some fair.ly effective 9 ongoing projects established under the earlier goals. 10 They have accomplished this in a rather interesting way, which I suspect, Jerry, is the reason why this one 12 is brought to our attention for action when the others were 13 not, rather than simply for information as was the case 14 in Alabama and Ilew Jersey. 15 What they evidently did is as follows: The 16 RAG charged their three planning, review and management 17 committees, which are the education, health manpower and 18 health services development, to develop essentially.what 19 we@e prospecti for the next -year's activity. What they did 20 essentially was develop 29 contract offerings of about 21 $25,000 each which were sent out on a mailing list of over 22 7@000 people in the state of Minnesota. From that they got 23 back 68 applications:ftom 38 different organizations. 24 Forty-three of these were approved and, if you will forgive '40al Reporters, Inc. 25 me, prioritized, and were included in the appiicatio n. I This somewhat unusual approach on the surface looltcd 2 like that what they were doing was really creating contracts, 3 but as you really look at it, essentially what they have io 4 done is decided what it is they waDt to do in the region and 5 they have just simply developed a communications device that 6 has been more effective than some in getting projects back into 7 the region to work on. 8 They did provide some freedoms in that they suggested 9 that there might be some variations on the prospecti that they 10 sent out that could be accepted, as weil.as a few came in which 11 addressed themselves to the goal but were different than the 12 original 29. 13 These projects or contracts have been reviewed in 14 detai I by staff, by SARP, and by the kidney review panel. 15 I might comment first on the kidney proposal which 16 they had which was divided into three components, a 17 professional and public education component, a hypertension 18 screening component, and a transplantation, tissue 19 typing, dialysis, blood bank component. The kidney review 20 panel recommended not only disapproval of the entire kidney 21 Project, but actually recommended disapproval of each of the 22 individual components of it. And I see no reason to disagree, 23 and it would save me some major problems as well. 24 SARP recommended that they be funded at the 1.450 el., Reporters, Inc. 25 level, which is equal to the,level already approved by us I and approved by Council for the 04 year, This is roughly 2 $300,000 above the current level of funding, but significant' y 3 below that which they have requested. This would enable 4 them to continue their core operation at approximately the 5 existing level of funding at the developmental component of 6 $115,000 which we have previously approved, both ourselves 7 and Council, but which had not been funded by Northlands due 8 to the previous commitments they had on ongoing projects. 9 It would also enable them to continue some of their. 10 ongoing projects and studies, and at the same time add 15 11 of their top priority rank projects that came out of the 12 prospecti as well as eight in the Second priority. 13 All of this is possible with the addition of only 14 $300,000 because they are phasing out eight ongoing projects .15 this current .-Year. 16 1 have some of the same concerns that SARP mentioned 17 as they went through it, that it may be difficult to manage 18 as many as 23 small contracts or projects as a problem. The 19 only feeling I had of a 'positive nature was that if they can 20 apply the same techniques that they have used for the 21 internal management of their staff to mana-ing those projects 22 then I think they will be able to handle them. 23 I also concur with the comments of SARP that they 24 need to place emphasis on initiatin- fairly early on'in @40 Repottets, Inc. 25 those individual contracts emphasis to pick up support for 1 them at the completion of their funding. 2 So I especially concur with the SARP recommen dations 3 that they be approved for funding at the 1.45 level, and 4 that there be no kidney proposal accepted at this time. 5 John is the second reviewer. 6 DR. KRALr@,IVSKI: I can't add a great deal to that. 7 In looking over these projects and not having site visited thi3 8 region, it appears that these projects would make a 9 contribution to achieving their goals. 10 It looks as thoufrh the RAG is.active in the decision- 11 making prr-:ess, and the----fore would apparently help formulate 12 this list in the order that it is in. I think the critical issue is Nvhether the organization 14 -I.s capable adminisLrativel-I of handling this kind of 15 activity, and I think if we look at the fact that at least 16 the reports that c=e from the site visitors, the reports that 17 we have had in writing and verbal, indicate that this is a lp strong area. The administrative staff is well organ ze 19 ane they have done a good job in r-inning their project so far. 20 So I think on that ba sis probably we could conclude 21 that they will be able to ha,-die this kind of decentralized 22 activity, particularly since they have been able to develop 23 some pretty good control mechanisms on staff activity and core 24 activity. 'I Reporters, Inc. 25 So I would concur with the recommendations -you have I Just made, and would put that in the form of a notion if you 2 wish. 3 DR 711URMAN: Second. 4 DR. MAYER: Len. 5 omment, and that DR. SCHERLIS: I only have one c 6 is they must be blessed with a great gift of wisdom to be 7 able to give a priority rating to 43 projects and ass ign 8 ranks to each of them. I think that that is a very, very 9 difficult feat, and it would be very interesting to see how 10 they arrived at -.t. I would concur with what you said, but 11 I think it is amazing t- have a group be able to assign 12 priorities to 43 discrete items and quite diversified projects 13 like this in that manner. 14 IIRS . n@LE: I think it is interesting because to 15 I think the committees did the first ranking and then they 16 were interdigitated. 17 DR. MAYER: There Nveren't just 43, there were really 18 68, because there were 25 of them that they bounced out 19 as 3aying no go, they are not good enough. 20 DR. B E.S@S ON I'm fascinated by this approach, 21 and I think that the idea of setting priorities first and then 22 having people devise project!3 that,you say yes or no, whether 23 they meet with your priorities, is the very reverse of the way 24 we have been seeing the whole thing operate right along, ial Reportcrs, Inc. 25 and I think is a very interesting approach. That's really what we're doing Vis-a-vis the region. And while we say 2 yes or no'to funding, they just-have the same kind of decision 3 to make, yes or no, to awarding a contract. I think it is 4 a very interesting approach, and it will be interesting 5 to see how they develop. 6 DR. @LKYE, RAdditional comments from staff who were 7 at the SARP review? 8 All right, the mot ion then is to accept the 9 recommendations of SARP at 1.45 level with no kidney ef fort 10 included in,'it. 11 All those in favor? 12 (Chorus of "&yes.") 13 opposed? 14 (No response.) 15 I would like to take a couple of minutes to see 16 if there are any further comments about the Connecticut 17 activity. As we indicated to you -yesterday, there were some 18 materials that were incorporated in the back of -your book 19 which we suggested that you might want to take a look at 20 for further discussion. 21 Yes, Joe. .22 DR. HESS: I read iiith some interest the comment 23 here that Council believes the question concerning investing 24 heavily in a state so Y,,iealthy in resources is completely I Repoitets, Inc. 25 irrelevant, and I wonder if that is an overstatement oftheir views or if they really believe that, because it is hard for 2 me to accept that as being valid from an advisory body'of.a 3 federal governmental agency. 4 Now to say that we should look purely at the merits, 5 or let's say the RIIP should look purely and only at the merits 6 of the program and have a system where the excellent programs 7 get more and more money, and by and large the areas that have excellent programs have already got more resources to begin 8 9 withp this only tends to increase the disparity between 10 the upper and lower ends of the scale of health care around thE country. And it seems to me that that is in a sense going 12 contrary to one of the basic purposes of the federal 13 government in this country, and I just have a great deal of .14 difficulty in understanding or accepting what I read into that 15 kind of a comment. 16 DR. MAYER: Would someone at the Council meeting car( 17 to elaborate on what they thought the intent of that 18 statement, whether that was a fair statement of how they 19 felt about it? Is there someone here on staff who was at 20 the Council meeting? 21 ?.M. CHAMMLISS: Judy. 22 DR. MAYER: Judy, the question that is being raised 23 is the issue -chat on the Connecticut proposal in which the 24 Council altered the recommendations of this group, was that 'Ibal Repotters, Inc. 25 one sentence statement that said "the Council believes that th( qu in- investing heavily estion concern in a state so wealthy in resources is completely irrelevant," and Joe has raised .2 3 some questions about did they really say that, and if they dil, 4 did they really mean it. 5 MRS. SIILSBEE-. I think they did really say that. 6 DR. SCIIERLIS: My reaction to that might be that it 7 was posed to us that one of the reasons we were interested in 8 the approach of Now Jersey was because that is such a rundown 9 --tate, and I would suggest that we can't do both of these things as appro@hes in a logical manner simultaneously. 10 11 Either we exclude -- arl I would call for a revision of 12 my New Jersey vote if that approach is not to be relevant. I think just as we can lo@k at a have-not state 14 and feel very strc;..igly tha+ we might apply other standards, 15 we have a right to look at a have state and have certain 16 standards. Is my point of view is out of line with Council 17 program? If so, all my votes should be reconsidered. 18 Would ycu care to res pond to that interesting 19 po-nt, Judy? 20 MRS. SILSBEE: I think perhaps the Council and 21 committee should get together on the subject of Connecticut 22 because we can't act as go-betweens. 2 3 M. SCIIE-RLIS: We have been told to emphasize 24 urban problems and dense populations. @4DReporters, Inc. 25 MRS. S11.13BEE: Couicil is looking at the Colitiecticul I program as a different type of program and they feel that 2 it needs support as a different type of pro-ram. 3 DR. SCI-IERLIS: I guess the statement is what 4 troubles me. 5 DR. MAYER: Yes, Jerry. 6 DR. BESSON: Well, I think there may be a source of 7 confusion here as to what deserves support. I think R?,IPS 8 has continually from the beginning awarded a meritorious 9 program. Now whether a program that is meritorious involves 10 a have-not area or a have area is what I think they considered 11 to be irrelevant, and - can live with that. 12 DR. SCIIERLIS: I can live with that. DR. BESSON: And I think that's all they are saying, 14 that ConLeoticut is a ver@ meritorious program, and if that's 15 the case the fact that they have a higher per capita income 16 and a higher dollar am,3unt from RTIPS and everything else, 17 that is irrelevant. That's the only way I interpret it. 18 DR. SCIERLIS: Is that the way you interpret it? 19 ms with DR. MAYER: Joe has SOM3 proble thatg I 20 think, if I heard him clearly. 211 DR. HESS: That's right, 'I certainly do, because 22 I fully concur with the need for a meritorious program for 23 funding, but I think there comes a point where some regions 24 you know, we have got to anticipate some leveling off as we ,c eal Reporters, Inc. 25 try to -- let's say the have regions in terms of funding, and I not a continual escalation of funding just because t ey 2 are meritorious, because there's only X number of dollars 3 in any one year to spend, and I think that sure, we would 4 like to see excellent RI.IP's in every region of the 5 country and we are working toward getting that by a variety 6 of mechanisms which we use here. But I think that there 7 will need to come a point where there needs to be kind of a 8 damper on the have regions 'who are excellent; otherwise you 9 sort of say the sky is the limit and you end up spending 10 proportionately more money on the have.regions,than the 11 have-not even though the have-nots may be on the way to 12 developing better programs. .13 DR. DESSON: Okay, Joe, but this is the first time 14 we are beginning to speak of a rational way of comparing. 15 regions. Up until now our decisions were completely 16 dependent on the time of day and how tired we were and who hac 17 more money, and it was all very haphazard. But now that 18 we have an order of relative ranking for the first time we 19 @e being able to use them I notice that the use of PPBS 20 in New Jersey is commended, as though that's something that 21 was discovered yesterday. Well, that has been around for 22 a long time, and why RMPS has never used it I will never 23 understand. 24 But there we are, we are just -- r,.,@LP is being dragged C40al Reportefs, Inc. 25 clutching and screaming into the current era. Unfortunately, I the kind of thing that -you are asking for, we are just 2 beginning to do it. 3 DR, MAYER: Comments? 4 VOICE: Yes, I th.ink the comment about the relevancy 5 in relationship to the state developing resources is due to 6 the fact that possibly the state that is wealthy in resources 7 may very viell be the best place to demonstrate or experiment 8 with some of this. I think this is part of the reason for 9 the statement, justification for the statement. 10 DR. BESSON: I have difficulty living with that 11 Connecticut decision for an entirely different reason, and 121 that is the big concern that we had here was -yes, they were 13 asking for a lot of money, but if t'-',s was a surreptitious 14 way of supporting rpdical schools that was a bottomless pit, 15 and if -je were going to get into that then we really wouldn't 16 have any vtoney for health care delivery changes. And for 17 the Council to consider that the only notion that apparently 18 made them reverse our decision was that this was an 19 innovative program, I think Connecticut has been extremely cleNe, 20 in using cliches in just the right way to push the right buttor 21 here in RMPS, and that'-- unfortunate because I think the 22 emphasis in Connecticut for the amount of money that is being 2 3spent is somewhat misdirected. 24 DR. MAYER: I'm delighted that we made as strong a .Skl Repotters, Inc. 25 point of the two or three iss,ies which we made on this one, n amel-y the concerns about support of faculty and the need to 2 revolve that, and where do those medical schools stand 'in 3 terms of picking up their responsibilities, number one, at 4 some tii-ne in the future; and the second issue which relates tc !5 the longstanding concerns relative to organized medicine in 6 that state, and then the issue that Joe has raised that we 7 discussed at soma length previously. 8 I just hope that since I won't be here beyond the 9 next meeting, that that has gotten so well documented in 10 people's thinking that three -years from now somebody will 11, be looking at how much of the lederal dollar through RNIP 1 2 is going into facilities of those medical schools, and somebody 1 3 will also be looking at the time of the next triennium beyond 14 -the surface about how are they really rciating to organized 15 meqicine in that state. 16 Other comments? 17 I would just like to make one other additional 18 comment on something that would be helpful at least to me as 19 an 'individual. I asked the question initially when me 20 started on these priority rankings were they the summation 21 of the weighted, and the answer was yes, they were the .22 summation of the weighted. I would like to see a correlation 23 between the summation of the weighted and the overall 24 assessments and how that works out, and I hope somebody is c at Repoitets, Inc. 25 looking at that because I sure would like a report of that to find out how high that correlation really is. And I @2 would like to have some of that data so I could look back 3 and think, you know, maybe that overall assessment component 4 is meaniDgfUl. And I hope some further detailed analysis 5 of this interms of what weights ought to go and are they 6 related to overall assessment or not by factor and subfactor 7 is going on. 8 But I think for now what I would like to know is 9 the sums of all of the above, plus the overall weighting 10 and how that looKs at the next meeting.. DR. SCIMRLIS: Maybe we will find one of the members of this committee always is right at that average point and 13, we can let him cast all our votes. 14 /Laughte.- 15 M. MAYER: Right. You know, Harris and Gallup, 16 they learned that a long time ago. 17 Any other items of business to come before the group? 18 Yes, tlr. Chambiiss. 19 MR. CHPIIBLISS: The queFtion was raised initially 20 at the beginning of the review about travel and about your 21 reimbursement, and I simpi'y,'-fouid like to say that we have 22 checked with our travel office. All of the payments from 23 October forward are now at the Treasury, and you should be 24 getting them within two week,-,. ,4bl Reporters, Inc. 25 I know you have heard that before, but I do I understand that they are in fact there. And perhaps but 2 for the holidays you would have heard from them. 3 DR. SCI-EERLIS: Which Treasury is that? 4 (Laughter.) 5 DR. t@IAYER: Of the United States, that is. 6 MR. CIWMLISS: The disbursement office of the 7 Treasury. 8 DR. IIAYER: Any other items of business? 9 Thank you very much. 10 (Whereupon, at 3:50 o'clock p.m., the meeting was 11 adjourned.) 12 -13 14 15 16 17 18 19 .20 21 22 23 24 Repoiteis, Inc. 25