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.