Rockville, Maryland~ 4 August 1971. . ACE - FEDERAL REPORTERS, INC. - Official Reporters J | 7 415 Second Street, N.E. | - Washington, D. C. 20002. (code oy saraze NATION-WIDE COVERAGE CR-3037 GIBSON ng 1 e 3} ONO LD 10 HW @ - 412 13 14 15 16 17 18 1 20 @ 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Wealth Services and Mental Health Administration NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS Parklawn Building, Conference Room G/H, Rockville, Maryland Wednesday, August 4, 1971 CONTENTS 2 || APPLICATION: | PAGE: e 3i| Albany ~ 53 4) Bi-State - .37 5 california (S.V.) - 3. 6|| Central New York (S.V.) | 58 71 Georgia (S.V.) 39. 8I Hawaii . 17 Maine | LO6 10) Memphis —_ ; 68 11f} Metro D.C. 112 © 12|| Michigan | | 103 13] Nev Mexico . G 129 141] Northern New England , 21 15|| Rochester | 62. | 16]| Texas | | 27 17 Tri-State | 139 1g|i Virginia 31 19|| Yisconsin 105 204 "910" National Kidney Foundation 141 @ 21 22 23 24 Ace — Federal Reporters, Inc. 25 10 i ©} 12 13 14 15 16 17 18 19 20 @. 21 | 22 23 24 Ace =Féderal Réporters, Inc. 25 PROCEEDINGS a ne eo DR. MARGULIES: In the interest of sticking to various time schedules and getting our Council meeting over with promotly, we will begin now without any further hesitation. We do know who has the earliest kinds of leaving schedules and so on, and I think we can adhere to that and not run into any difficulties. I don't know when Dr. Brennan is coming. We assumed he would be here and we haven't had word to the contrary, so perhaps he'll come in a little later. So we will start the program review now. We will take up those first which will make it convenient for those who have to leave earliest and I will turn that part of the meeting over to Dr. Pahl. DR. PAHL: Dr. Millikan, Dr. Everist and. Dr. DeBakey have somewhat earlier departures, so with your permission, I think we would like to rearrange the order of our reviews and start with California. Dr. Millikan. May I also ask the appropriate staff to sit at the end of the table and add their comments as before, and the regional office representatives, following their meeting this morning, will be in to also participate on the individual applications as appropriate. DR. MILLIKAN: On June 10th and llth, 1971, there was a project visit to the California Regional Medical Program and 10 W ©} 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 abbreviated or synopsis version of the project site visit report and you have, I believe, under the California.tab, a green There's a longer one also available that has been distributed. In any event, there are several interesting kinds of problems that are symbolized by the California Regional Medical Program, and I suppose one of them has to do with the potential differences in ovinion between project site visitors and between, the total concept of the project site visitors, and that of the review committee. It also exemplifies the potential agiffi- culties in the triennial review process when we're dealing with. an altered budget structure from year to year, and that has inherent in it some difficulties in the judgment process with the rest of us because of some differences in quality in the subdivisions of the entire Regional Medical Program. Now, if you look at the first page of the blue sheet, you'll see a series of recommendations and the first one addresses itself to a portion of the original application after the one kind of plan and the other to a second kind of plan; and ultimately you see there's a recommendation down here for $6.2 million per annum for the California Regional Medical Program. Now, I disagree with this recommendation as a project site visitor and as a member of the Council, Lf that's where we're going to stop with our potential action, and in trying to interpret the summary represented by the blue sheets, it seems 10 11 12 13 14 15 16 17 18 19 \ce = Federal Reporters, 20 -21 22 23 24 Inc. 25 likely that a portion of this judgment to make such a recommen- dation was arrived at because of the fact that a couple of these subdivisions, which in actuality are regions, are very poor. and if you look at the nine that make up California, one can see unequivocably that what's called Area 1, Area 4 and Area 5 are among the very, very best in the United States, consisting of San Francisco portion, the U.C.L.A. portion and the U.S.C. portion, the latter two having been the two that combined to initiate the action that has been consummated by the formation of the ninth area which is the one at Watts-Willowbrook or the . Drew School and King Hospital area. | These are offset, as one looks at the total program, by a couvle of areas that among the very poorest, and this is San Diego and Oberlinden(?), 6 and 7; and number 8 has one good program and that's the Irvine-Orange County area. ‘ It has one good program, the community stroke program, and that is about it in terms of what's actually gone on in that entire area, . which, of course, is over several years. And, as one talks rather candidly to the personnel of that area medical program, they don't have much in the way of plans for anything more, if you recall, at the time of our project site visit. So, I think that while the California concept seems to me continues to be working, that is having nine regions really amalgamated under and working through a central office, I think that phenomenon is working pretty satisfactorily. There 10 1 @ 12 13 14 15 16 17 18] 19 20 @ 21 | 22 23 24 Ace ~ Federal Reporters, Inc. 25 are certain disadvantages inherent in the situation where you put very, very poor quality area in combinetion with a very, very good one and ask people to assess a budgetary outlay on the basis of their total reaction to this. So this is one of the problems inherent in the California Regional Medical Program grant application. Now, the next item that I have already mentioned has. to do with the problem which might be a delightful problem which might be created if in a year or 18 months or two years we had a considerable change in the budget base from which we operate. In other words, suppose that our allocation and appropriations in Congress is actually released and is considerably increased - by $30, $40, $50 million; and a program like this California one is locked in to its triennial review process to $6.2. Well, llwe would simply keep in mind that that would be the height of inequity, at least that's my opinion about it, and we would need to rereview the thing. Now, there's one possibility that we could take an action at this point in time, because there are two plans lactually in front of us, plan A and plan B, which could make some allowances for an altered budget structure if there was one Vat the end of the line. Now, the review committee has a little bit of a dim \ view of plan B. Well, I-think most of us on the project site visit seemed -~ didn't see anything very materially wrong with 10 1 13 15 16 17 18 19 20 @ 21° 22° 23 24 Ace =:Federai Reporters, Inc. 25 14 plan B at all. I don't know what the others' reaction is, but olan B sounded like an entirely equitable plan. One of the points about the whole triennial review process and about the kind of internal guidelines that we approved yesterday unanimously at this table was that we are in essence giving what might be called a bloc grant. After careful and full review and inspection and deliberation, we are saying "For each of the three years we are going to give you 'y' amount of money and you become the decision-maker as to the precise way in which various portions of this money is spent," And so what we're really talking about here in plan B is an increased total funding and it was the review team's opinion that these people are highly competent to make decisions about how to wisely -- it was the project site visitors' opinion that the California, the ccrMp and its subdivisions are highly competent to make decisions and good decisions about how to spend that quantity of money. So I think that probably there would be a series of comments from staff and I don't want to belabor this issue any further, but I am summarizing my ‘own reaction by saying that within the context of what I've been commenting about that I have some disagreement with these blue sheets. there's some people here in the room who were on that project site visit and studied this thing at great length. a 7 t } DR. PAHL: Does staff have any comments to make 10 Vy © 12 13 = atl + omen vmod; a met cNOs cor SNe ON Ur “dO 22 23 24 Ace ~ Federal Reporters, Inc, 25 ‘relative to the discussion? MS. SALAZAR: _---— think that you can say that the blue sheets reflects the consensus of the reviewars, as Dr.. Millikan has pointed out, with the recommendations stated on the first page. It's a rather large team, as you can tell from this report, and has received further information since returning. DR. PAHL: Dr. Ochsner, have you any comments as the other reviewer? DR. OCHSNER: No, I haven't. MS. KYTTLE: Dr. Millikan, did I understand you correctly when I thought I heard you say that it was your interpretation that the blue sheet was recommending $6.2? DR. MILLIKAN: Well, to. go through this, they don't recommend $10,043. MS. KYTTLE: No. I was of the opinion that the intent of the blue sheet was to recommend $8.3. DR. MILLIKAN: Minus 121. MS. KYTTLE: Well, the kidney panel had met later and restored the 121 which got it to $8.3. DR. MILLIKAN: Correct. And what I'm trying to emphasize here is that I think we either ought to make dual recommendation or say that we will bring this back to the review process if and when there is more total money in the RMP kitty short of the three-year process. oe NE ~. * 22 23 24] Ace = Federal Reporters, Inc. 25 25 pase and this peer review, which is going to be monitored by the medical societies. So there has been a strengthening and it ‘has status. DR. MILLIKAN: From what I hear is they're sort of getting other grants to do the things that ordinarily RMP might do. MR. COLBURN: They have had an impact also on formulating B agencies in the state. They just got planning awards for two B agencies. DR. KOMAROFF: One interesting thing that they were doing, a private general practitioner, Gene Bont, had opened up his practice to both quality audit and financial cost benefit studies in a rural general practice situation, using paramedical personnel for'a certain group of patients and not for others, using the problem oriented record, and this was just an inspiration at the time we were there but hadn't gotten off the ground. Do you know what's going on with that? MR. COLBURN: I really don't. Dr. Shyer I think was coordinating that and he's left and I haven't seen the progress reports. DR. PAHL: Mrs. Silsbee informs me that the regional loffice representative, Mr. William McKenna, knows a great deal of this and is at a meeting for a few more minutes and will be . . . : \ returning. Perhaps we could either defer the application or go on to the kidney aspect. 10 u 13 14 16 7 18 19 20 © | 21 | 22 23 24 Ace — Federa! Reporters, Inc. 25 26 MR. MILLIKAN: Well, I'll make the motion that ~- because I don't think we can phase this out or anything like that -- I would move the agoption or move that we approve the recommendations of the review committee, including recording the six items of their critique, under critique, with these items being kent very strongly in mind as we address ourselves ultimately to the acceptance of the triennial review application from them when it comes sooner or later, and that hopefullywe're able via the appropriate administrative leadership to see to ~ it that some of the real concepts of RMP are gotten into their program. DR. PAHL: All right. ‘The motion has been made to accept the recommendations of the review committee, including the points made under the critique in the blue summary sheet and with the further advice as stated by Dr. Millikan. Is there a second to the motion? ' DR. SCHREINER: Second. DR. PAHL: The motion has been made and seconded. Is there further discussion? DR. MILLIKAN: I think the problem here is exemplified if one reads those points, that here is a region which has been active from early on in the nistory of this division with the absence of a good set of goals, objectives and priorites. They could simply sit down and write those out from 40 other regions if you don't have any ideas of your own. That's pretty close to 10 1 13 14 15 16 17 18 19 20 ~4 © 21 22 | 23 24 Ace -- Federal Reporters, Inc. . 25 one could say that they were disharmonious, disgruntled, dis- 27 unacceptable, you see, to be in existence for five years and not have any good goals or objectives. f think that's the review committee's statement. If you look at number 5, the lack of a data collection strategy, and all they've been doing is collecting data for five years and they don't have any strategy for the use of any of it, according to the review. DR. PAHL: I'm glad you didn't say the goals and plans of 55 other regions. parhans 40 or so. Is there further discussion? . | (No Response) DR. PAHL: If not, all those in favor of the motion please signify by saying “Aye.” ("Ayes") DR. PAHL: Opposed? (No Response) | DR. PAHL: The motion is carried. I would like now to turn to the application from Texas, with Dr. Everist as principal reviewer. “DR. EVERIST: For those Council members who remember the early history of Texas TMP, this review will be refreshing. For newer members, it will be a revelation. By using the most euphemistic recordable descriptions of the first three years of the Texas Regional Medical Program, \ believing and distressful. it e 1 13 14 19 16 17 18 “19 20 @ 21 ‘ 22 23 24 Ace — Federal Reporters, Inc. . 25 28 There were a variety of organizations competing for whatever it was they felt RMP could deliver. By some strange alchemy, the current coordinator, Dr. Charles McCall, has enticed a phoenix out of the ashes. Texas is still not a ‘showplace for RMP, but it certainly has seen the light of the ‘1970s on the horizon. Texas has about five percent of the nation's popula-_ ‘tion scattered over an area of 267,000 square miles and they ‘have recently rediscovered subregionalization. In the past, Texas has had difficulty measuring its goals and priorities ‘with the national goals and priorities. The fault was probably bilateral, but that was the past and the future looks better. The grantee institution is now the University of Texas system with offices in Austin, and is also now the fiscal ‘agent, and they are requesting triennial review with a total of — a three-year funding of $5,632,416. This would include a ten percent developmental component for three years, core, and three new projects; one approved unfunded, plus eight continuation projects for one year; two for two years; and two renewal projects for one year. They are also requesting earmarked kidney disease funds on a non-competing basis for a period of three years. The project orientation which currently entraps a fair amount of the substance of the Texas RMP has not been signally | successful with perhaps two exceptions. The newer programmatic 4 nm an oN P4 sce - Federal Reporters, inc. Os ‘| adopted a “wait and see" attitude. Be od jt | one year. This is only $125,000 less than they requested for i for the third year. 29 sopreach seems to have a regional concept well in hand and shows . true concern for the deficiencies in the health delivery ‘ : system, especially for canpulas and blocks. Examples of this are an attempt to improve the quality of care given by black physicians, the high priority placed on a project called GRO, to orovide in-service training in small rural hospitals and the employment of a regional staff, now three, potentially ten, and selecting these employees from local, knowledgeable, effective people. The managerial hierarchy of the program would seem to be most adequate and the new coordinator almost beyond reproach. | The review committee has solved the very sticky problem of how to react to the past and a good future is a from their site visit anda written proposal. They recommended $1,590,000 a year for two years to improve the developmental component. They are not placed on triennial review but a site visit will be made at the end of the first year and a little than $300,000 under their request The committee has expressed their faith by allowing she developmental component while at the same time they have I, therefore, recommend approval for two years ata 4.00 1 funding level of $1,590,000 including the developmental funding. 2), DR. PAHL: .Thank you. “Before we place the motion eo . - | 3\lbefore the Council, perhaps we might ask Mr. Friedlander if | | 4 there are any comments he would like to make. | 5 MR. FRIEDLANDER: After years of listening to Dr.. 6l|\Everist-do such a magnificent and incisive job of reviewing 7ithe review committee's recommendations, I couldn't possibly add '8t anything. ‘9 “ DR. PAHL: The motion has been made for acceptance 10 of the committee's funding recommendations. Is there a second TLito the motion? - 12 + DR. FRIEDLANDER: Second. 13 DR. PAHL: Is there further discussion? Mr. Posta, {4\\do you Have anything? ‘” 7 7: MR. POSTA: That suits us fine. 16 DR. PAHL: If there's no further discussion, all those 17ijin favor of the motion please say "Aye." 18 ("Ayes") 19 DR. PAHL: Opposed? 20 (No Response) 211 DR. PAHL: The motion is carried. 22). DR. MARGULIES: I wonder if I could just make one 23);comment at this point. The review of this region with its a , , . . . | 24 }past history and present status which came through with the kind Ace ~ Fedefaf Reporters, Inc. . . . . . . : : vee et 25 of enthusiastic summary in review committee as it has in Council, 10 11 © (12 13 14 15 16 17 18 19 20 © 2) 22 23 24 Ace-—Federal Reporters, Inc. 25 ne 31 again illustrates what we keep talking about with the RMPs from one moment to the next, and that is what kind of leadership is present and what that leadership can achieve, and this is an_ ideal example of what a difference it makes and we have some other examples of what a difference it makes which are less pleasing. DR. PAHL: If we may now go to the application from Virginia, Dr. DeBakey. DR. DE, BAKEY: Well, the only thing to go by is the recommendation of the review committee on the blue sheet, and I would be inclined to go along with their recommended funding. I must say that I had some feeling that this may be inadequate. Is there someone here that has better information than is available in these sheets about the reason why they have cut back on some of the support, particularly in relation to supplies and equipment? | | DR. EVERIST: It's two centers. DR. DE BAKEY: JI know that, but I'm talking about the -- DR. PAHL: Mr. Spear, could you perhaps comment on the funding recommendations? MR. SPEAR: The Virginia RMP has had a great potential for activities in renal disease and the application that was 4 received reflected at least some very good things that needed to be done, but the panel was unsatisfied with the kinds of 10 WW @ | 12 13 14 15 “16 7 “18 19 20 ® 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 duplication of effort described, and the central difficulty was i} activity, the panel was willing to act on with some specificity ‘l}because I get the impression that they felt that this was in 32 descriptions that were given about the activities. Their goals were not well described in some respects. There was some clear ‘one, not unusual in many regions, that there was a need for further cooperation and coordination among the activities “involved in renal disease. The activities related particularly to a dialysis ‘and the review reflects that. The knowledge of the panel about ‘the four vossibilities in the region led them to desire that ‘there be some conversation to see what are the base needs that can be met within the application that was submitted. ‘parts of the application without further discussion face to face good hands, and certainly Dr. Hume is able to give good leader- ‘ship for this, there's no question about that. MR. SPEAR: Yes. DR. DE BAKEY: And it seems to me that cutting back on some of the funding that this is going to jeopardize their ability to do the job well, particularly when you have as good leadership as you have in the renal disease area as exists there. MR. SPEAR: 1 think the key statement there is that They were just unwilling to make some decisions on somp DR. DE BAKEY: Well, the reason I questioned this is | @ 12 13 if 15 a SONt ot mm 18 r 21 24 Ace-~ Federat Reporters, Inc. 25 33 those funds be used as a base for discussion. This much could clearly bé approved with no difficulties: that there might be a need for more was well recognized, but it needs to be clarified. DR. EVERIST: There's a site visit coming up next month in virginia and there could well be a kidney man put on the site visit team and recommendations given. DR. DE BAKEY ; Well, I certainly would go along with that. That's a good suggestion in my opinion. I certainly would be willing to approve this, but I think we ought to take into consideration that there is a possibility, perhaps after the site visit in another month, and we have an opportunity to review this again and bring it back to the Council, if the site visit demonstrates there is a need for the additional funding, I think we ought to be open to provide it. : I just am a little concerned about cutting back on the funding of a group of peole that I have great confidence in and admiration for in terms of what they're able to do in this area. DR. MARGULIES: I got the impression when we discussed this earlier after they had been down there, Mike, that the people were there but they really hadn't gotten together. There were some terrible gaffes in which an application was in with somebody's name on it and he discovered his name on there for 34 1] the first time when the application was in. It's that kind of 2\| disjointed effort. It's there but it hasn't been pulled @ 3||° together. 7 ! 4y, DR. DE BAKEY: I was on a project site visit in 5) Virginia well over a year ago, and at that time I got the 6{ distinct impression that there were some polarizations as well 7\in certain parts of the state, but it seemed to me that much 8lof this has improved, that they were getting together and were 9 trying to work it out, and particularly the renal program is 10’ one which was receiving the support of everybody. So I was 1l{ particularly anxious to see if maybe this would be a good ©} 12! mechanism to demonstrate how they ‘could work together to help 13/f all the people and particularly people that are in need -~- the © 14/f patients that need this type of management. wai DR. SCHREINER: May I ask what the status of project 1é|' 12, procurement, what the status of the funds was? 171 , MR. SPEAR: Yes. I wanted to comment on that. We 18) have been providing funds for the organ procurement development {¢fin that area and, in fact, that's the key point for the whole 4Q|| southeast area of the country, and we have just provided a @ 9} third year of funding for organ procurement development o7} activity which is expected probably to be the final funding, but 23) we wanted to look at it again at the end of the third year. \ 24 DR. SCHREINER: I think, just to back up what Mike is Ace — Federal Reporters, Inc. . . . . . , 95|)saying, that at least in that particular program it's functioning 101} wit eo i ‘for a physician part-time in here. Does this represent a 13 14 15 16 17 18 19 20 @ 21 22 23 24 Acé =Federat Reporters, Inc. 25 "typing and kidney -~ pretty well. If that goes down the drain, that's the hub of the whole 12 or 13 university network that's getting the ~ DR. PAHL: Dr. Merrill, did you have a comment to * make? DR. MERRILL: I just wondered, this is labeled Virginia Regional Medical Program and I would assume, as ‘pr. Schreiner just mentioned, that it deals with patients from ‘areas other than Virginia, and I gather that's perfectly appropriate for this program; is that correct? DR. PAHL: Yes. DR. MERRILL: I notice also that there is a salary “oy ‘departure from the policy which we discussed yesterday? MR. SPEAR: You're looking at the figures here? DR. MERRILL: Yes. MR. SPEAR: The proposal, among the other things it VY talked about, was the development of two satellite dialysis units and the key to these units was that one was to be for paying patients and one was to be for indigent patients. One was to be » relatively fancy and one was to be relatively plain; and the panel couldn't accept that philosophy. So this repre~ sents their judgement of faults that would be encountered were a single dialysis satellite were to pick up both the paying and the indigent people. 10 VW @ 12 13 14 15 16 17 18 19 20 @ 2) 22 23 24 Ace — Federal Reporters, Inc. 25 36 DR. MERRILL: But the services of physicians who would be essentially rendering service to patients is included in that? . MR. SPEAR: Yes. DR. PAHL: Dr. DeBakey, was that in the form of a specific motion for concurrence with the committee's recommen~ dation but that should be subsequent should the site visit indicate a need for additional funds that this request will be brought back before the Council? DR. DE BAKEY: Yes. DR. PAHL: Is there a second? DR. EVERIST: Second. DR. PAHL: Is there further discussion? (No Response) 1 DR. PAHL: If not, all in favor of the motion please say "aye." ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. DR. DE BAKEY: I think Dr. Everist's suggestion to have someone from the kidney disease panel on the project site visit would be desirable. DR. PAH: Yes, we will have appropriate representa- tion from the staff and the kidney disease panel on the site \ 10 i ©} 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace ~Federal Reporters, Inc. 25 37 Now, we're hoping for Dr. Brennan still perhaps to make it to the meeting so with your permission I would like to take up the Bi-State application with Dr. Ochsner as principal reviewer, and we'll hold the New York applications pending the arrival of Dr. Brennan or at your pleasure. DR. OCHSNER: I haven't made a site visit there and I don't know when the last site visit to Bi-State was made. I think you're all aware of the fact that this is one of those hodge-podge regions in which it involves a large metropolitan area, St. Louis, and two fine medical schools and then a very large rural area in southern Illinois. Apparently they have a strong coordinator, They have difficulties because of the type of arrangement with the many diversified interests, but apparently they're doing a fairly good job. I would recommend what the review committee recommended, that there be an additional year instead of the three years requested, and this be in the amount of$924,113. DR. PAHL: And your recommendation includes the 1} concurrence with the committee's disapproval of the develop- mental component and the other funding relative to the projects? DR. OCHSNER: Yes. DR. PAHL: Dr. DeBakey, you were backup reviewer. Do \ you have any special comments? DR. DE BAKEY: No. I would agree with that. 10 1] 13 15 16 17 18 20 © 21 22 23 7 «A 24 Ace ~Federa! Reporters, Inc. 25 14 38 DR. SCHREINER: I wanted to ask, what's the status of the proposal that they were preparing on a multi-regional renal training vrogram? Does anyone know? DR. OCHSNER: I don't know what the status is about that. All I know is what they've got here. MR. JEWELL: We do know there is an application in the mill. They have not yet formally submitted it to us but they are awaiting word as to when the doors open for 910 consideration. DR. SCHREINER: I knew that they were working on a very comprehensive proposal. DR.MARGULIES: Yes. That was Missouri, Bi-State and Kansas. They have been working on it. I get the impression from talking with the coordinators separately that they're finding this more difficult to do this together than they had anticipated and I have the feeling that they will come in more || separately with their applications and try to join in some way, but that's not necessarily true. I think that, again, this might be affected considerably by level of funding in the way |lin which we come back to them because the idea of combining over /that area is very sensible. DR. SCHREINER: It had some very exciting aspects in- one vlace where I thought we could exert a little leverage maybe, DR. MARGULIES: Yes. 10 11 © 42 i 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace +Federalt Reporters, Inc. 25 39 DR. PAHL: The motion has been made. Is there a second to the motion? | DR. DE BAKEY: JL second it. DR. PAHL: Any further discussion? Does the staff have further discussion on this application? (No Response) DR. PAHL: If not, all in favor of the motion please say "Aye." ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. We may now turn to the Georgia application with Dr. Cannon as principal reviewer and Dr. Schreiner as backup reviewer. DR. CANNON: The Georgia application has been studied both by the site visitors and the review committee and they turned in almost identical recommendations to approve the number of people approved in the recommendations that are before you and we've had a significant study. Now, there is one question concerning policy that we might take a minute to discuss. Both the site visitors and the review committee were anxious that some way be worked out to fund a program to stimulate underprivileged students in high school into the health care system. This received a gold star 10 1] 13 14 15 16 17 23 24 40 both by the site visitors and by the review committee. However, it's been the policy of this Council not to fund programs in career oriented programs. = In other words, sometime ago when we were discussing applications referable to different stratas in the personnel training of health care workers, we put a limit on the funding tof the schools. Isn't that correct? DR. MARGULIES: That's right and, of course, that issue came up during the discussion of that particular activity but the people who looked at it were so impressed by its potential that they felt that this was one time when it could be described in different manners or one in which you took advantage of the fact that you make your own rules and have the opportunity to make exceptions to them if you find it wise. | DR. CANNON: It's a very small amount of money, $23,000, in comparison to an application which is asking for $3.7 million per year at least, but it would require some change of policy. I would like to have the staff that recommended the Council reconsider it express their opinion. DR. KOMAROFF: Is this. something that could be accomplished out of core without calling it a separate project? DR. CANNON: It could be. | DR. KOMAROFF: Thus without violating policy. DR. MARGULIES: Well, you can, but I don't think we Ace — Federal R Inc. . ‘ . . : cow reeers eee og [need -~- it's our policy and I think that we deal with it as our 10 iW 13 14) 15° 16 17 22 23 24 Ace ~Federal Reportets, tnc. 25 41 DR. EVERIST: We don't need to change our policy. DR. MARGULIES: Miss Nelson, do you want to comment on this? ~ MISS NELSON: I was going to comment that on our policy, the last sentence, we do State that RMP funds may also be used in planning health careers recruitment activities. This is in spite of the fact that we said we didn't fund operational programs. It may be used in planning health career recruitment activities as a vart of and coordinated with the overall man- power strategy for the region, and do you see this aS a part of that endeavor in Georgia? DR. EVERIST: It's a moot question. DR. PAHL: We can waive it. DR. EVERIST: Sure. We can waive our own policy and just make an exception. 7 DR. CANNON: well, I believe that we're making a mountain out of a molehill because I think we could very well work out the funding on this. I think we'd sort of want to make an issue on it to see if there was going to be a policy change by the Council. My feeling is that we ought to express our interest but tell them that our policy is unchanged at the present time. I think he's well aware of it. I kind of have a feeling that \ we're kind of making an issue about whether we're going to change our policy or not. 13 14 15 16 17 18 19 20 © 21 22) 23' 24 Ace ~Federal Reporters, Inc. 25 ‘thing which Council regarded as a good thing to do so long as it 1 was done in a manner consistent with our policy, and he'll 42 DR. MARGULIES: I think we can describe it as some- understand what he then needs to do. DR. CANNON: All right. Now, as to the overall prograi you will note that both the site visitors and the review committee have recommended funding of $2.8 million per year instead of the requested $3.9, $4.3, and $3.9, and very clearly set out the reasons for deletion of this amount of money from that requested, and they were on the basis of programs in which they withheld funds or thought they had little or no relation- ship to the overall progran and not likely to remain viable without future support from RMP, and that they could be incor- porated in other projects. For instance, they have two respiratory projects that | deal with respiratory disease, one in pediatrics and one in adult respiratory diseases; and the fourth reason, it would be more appropriately funded from other sources of support. There is one question when you're tabulating the funds how both the site visitors and the review committee come up with $2.8 million. There is a questionable item and that's under project 6, communications network, a request for $160,000 and I presume that the recommendation is that this not be funded \ Now, I could not tell from what was given to me either on the blue sheet or the site team report whether the recommendation 10 WV @ 12 i3 14 15 16 17 18 9 20 . * 221 23 24 Ace.— Federal Reporters, inc. 25, 43 was for deletion of this amount.. DR. PAHL: Mr. Nash, can you help us out on that? MR. NASH: Yes. -The recommendation was not including funds for that project. DR. CANNON: Then, if you turn on the yellow sheet, to run down the projects that funding was changed, the state- wide cancer program with a cut of about 60 percent of the funds, and then the respiratory center and the facilities for respira- tory diseases were merged and that funding was cut. There was another merger of patient and family education with the learning resources and that funding was cut. Then the kidney disease program was dropped or cut. DR. MARGULIES: Bland, could I -- I just got a letter. 7 j . . yesterday and was waiting to get to this kidney one. This is one letter from Albert Tuttle and the other from Gordan Barrow : about the kidney proposal. They feel that this had an inade- quate review. and they feel very strongly about it. There was not a site visit, and they felt that to look at it from our point of view was out of context to the rest of the activities which are going on down there. And I indicated that we would be happy to withdraw that particular proposal from consideration at this time until we could have a site visit to satisfy their requirements. DR. CANNON: Well, what about the ad hoc panel on renal disease? “CON OO On i e° 8 13 14 20 @ - 22 23 » an . 24 Ace ~ Federal Reporters, inc.. 25 44 DR. MARGULIES: Well, the ad hoc panel did not nake a site visit and they felt that they had based their judgment on incomplete information and_ they would like to have them look at it more fully, and I thought their objection was valid as I went over it with the kidney division. So they prefer not to . : : ’ have any consideration of it at this time. DR. SCHREINER: While you on it, I had planned to make some comments on that area. One of the problems and I think we commented on this in the orientation sessions -- it's a. minor problem. The ad hoc kidney ‘review committee is very good, however it is pretty heavily loaded with four transplant | surgeons and sometimes their decisions reflect the surgical prejudices. ve Now, they just sort of took a sort of black or white ~ approach to the fact that there wasn't a surgeon there, and at the time they considered it there wasn't. They were in the process of recruiting a new chairman in the department of surgery. DR. DE BAKEY: They've got one there now. DR. SCHREINER: And they got a very fine one who has also committed himself to a transplant program, and he's very i} cooperative and very academic surgeon, and I would think that that was probably a kind of hasty comment that was made. The other problem was that all our negotiations were! with the young fellow who ran the dialysis unit who is a very - 10 | ie e 1 | 7 14 15 16 7 18 19: 20° e 2 22° 23° cs 24 Ace = Federal Reporters, Inc. 25 45 dynamic person who is leaving for personal reasons, and they sort of took that as a comment that the whole thing was going to collapse, whereas the fact is that the dialysis center at Greeley (?) is the closest of any unit in the whole South to fulfill the criteria that the NIH study group set up on the jdeal nephrology center, and it was partly set up with RMP funds. I think it would be a little unfair to pull the rug out from under it. DR. CANNON: This gives some insight as to the strength of our representation in the kidney -- very logical objections -- and I'll be discussing this further on another report ‘that I have. | Well, let's delete that from our consideration and say that such projects as physiology for nursing and nursing instructors and projects for dietitions and so forth, there were no other projects in question or programs in question except one, and both the review committee and site visit.team said that a plan for a health maintenance program at Stephens County, which is a county of about 20,000 people, will not be considered for funding on the basis that we no longer are funding new multiphasic screening testing. For those of you who are not aware, this is a small rural county and has an ongoing program such as this, you should look to Iuca, Mississippi. If you go down to Iuka, uississipoi, they have a program similar to the one that was recommended here Ace -- Federal Reporters, 10 iv 12 14 15 16 17 ii 18 Wy 20" 21 22 23 24 inc. 25 46 ‘in Stephens County. It is the key to bringing those people who haven't had health care into a health care system. It's a gimmick and it works very well with a followuo of health care. And we can't really analyze that on paper, as Clemmons' ‘committee did, as to the value of multiphasic screening because Wit's the byproduct of the technique that accomplishes something that we in RMP want to accomplish. So I would suggest that some further consideration ‘be given to the Stephens County health maintenance program so that it could be placed in a different context of its primary ‘purpose, and I do not believe that we should exclude funding ‘for that program; but, as I say, site visitors and reviewers have suggested that we do so. DR. KOMAROFF: Are adequate provisions for referral and continuing care provided in this? DR. CANNON: As near as I can tell from the material sent to me from Georgia -- Georgia has a very unique way of | getting their information with forms and things, so that we may not have all the information you want from them. Relying on the site group, maybe they could tell us. Did. you look into that program? MR. NASH: No. We didn't really look at any of the projects there from a technical aspect. They do have Followup \ built in the program. I think the reason the site visitors recommended no funds for this project was based upon the 47 1) policy or recommendation of Council that no further multiphasic 2 screening be approved and be supported. @ 3° DR. CANNON: Well, I would recommend that some way 4l| we would not change our policy for multiphasic screening, new 51 programs, but that we would support an activity such as this 6’ which accomplished the goal that's more important than finding 7 out whether multiphasic screening is a wise program to support 8) financially. Y You see, if we pass this, the way I look at it, we've |. 10} already acted against the recommendations of the Brennan report, 11) which we accepted. ©} - 124} DR. MARGULIES: Well, those recommendations were 13|| saying -- and I think this may be at least part of the resolu- 141) tion of the issue that you raised ~- they said that these 15° should be suspended until there can be a more adequate evalua- 16° tion of the usefulness of these kinds of screening activities, 17) and I think that if you want to take action on that pending 1g|| that evaluation, and we can then spend more time with them to 19 see whether this fits in with the other kinds of issues or not, 20), it gives us at least a way of responding. © 21 We don't know how long the evaluation will take, of 22'| course, and what the nature of it will be, but there is an 23|| intensive effort going on all through HSMHA to take a look at 24|| this multiphasic screening issue because it's all over the place Ace —Federal Reporters, Inc. . . 7 . 25|| and we may have some kind of basis in the near future of being 10 11 13 14 15 16|) 17! 18 20: @ 21 22 23 24 Ace — Federal Reporters, Inc. ; 25 48 able to lift our kind of prohibition on it. DR. MILLIKAN: Could we then amend the motion to include such a phrase as continued support for this activity you mentioned pending evaluation and appropriate further judgment concerning it? DR. CANNON: I would accept that. DR. DE BAKEY: Bland, you have some personal experience with this? | DR. CANNON: Only in fuka; I went down about a month ago, a little more than a month ago, to Iuka, Mississippi, | because I had heard so much about Iuka, Mississippi. and its program. DR. DE BAKEY: How did you happen to hear about it, because I never heard about it? DR. MILLIKAN: Haven't you, really? DR. DE BAKEY: No. That's why I'm interested. DR. CANNON: Well, it's a community on the periphery of the Regional Medical Programs in Memphis, and if there's anything that speaks well for working in outlying regions, I think this is the one place I would point to. And I wondered if the staff of RMPS has this impression. Would you speak to. it? MR. RUSSELL: Yes. I’ think you'd have to know Dr. Cosby who heads up the mobile multiphasic screening unit in ! Iuka. his was about ayear ago that, Dr. Cannon, it actually | 10 11 .13 14 @ 2r 22 23 24 Ace ~ Federal Reporters, Inc. . 25 49 got started and underway, a year or a year and a half ago. As a result of the mobile unit and the interest of the general practitioners in the area, they have stimulated a tremendous — amount of interest, not only in the mobile unit but they are bringing in other programs. They got the local mayors involved. It's really delightful. DR. CANNON: The main thing is bringing people in for health care that's never seen a physician. DR. EVERIST: I'm not sure it's appropriate to be discussing this because we are going to be discussing this in th Memphis region in just a little bit, and I personally have some @ifferent ideas about Iuka County. DR. MARGULIES: Dr. Everist, in his quiet way, is saying that this part of the discussion is out of order because © we're going to get to that next. DR. CANNON: Well, I'm not discussing Memphis. I'm telling you the value of a program which uses multiphasic screening, that we call multiphasic screening programs really ought not to be called that. They're using multiphasic screening to effect a program in getting started, a health care system for people that otherwise don't get in the system, and I say it's wrong to exclude funding of those programs on the dpbasis of the Brennan's Committee rpeort. DR. DE BAKEY: You're making a generalization, it seems to me, and I'm not sure that that's correct. Multiphasic VW Me On 10 1 13 23 24) Ace — Federal Reporters, Inc. 25° 50 screening has been around for a long time. It doesn't always do what you say it does. So it depends on who does it and how it's done. ~ | | DR. MILLIKAN: I thought he was not making a generalization. I thought he was making it specific. DR. CANNON: I wasn't generalizing, because it's Dr. Cosby that makes it work down there. DR. DE BAKEY: Is this Stephens County you're talking about? DR. CANNON: Yes. DR. DE BAKEY: And Iuka. is in Stephens County? DR. CANNON: No. Stephens County is in Georgia. Iukais in Mississippi. DR. DE BAKEY: What do we know about Stephens County? DR. CANNON: What I know is only there is a multi- specialty group that is prepared to take over this health i program for the community of which 25 percent of the population iis below poverty level. Now, if the 25 percent below poverty level are brought in for the first two years, no charge, for their screening and positives will be referred to physicians if they don't have a physician, with no charge health care will | rendered for those two years. DR. DE BAKEY: Fine. That's a good objective. \ DR. CANNON: And then, after that, it's supposed to generate it's own support. But to call it a multiphasic 10 1 @ 12: 13 14 15 16 174 18 19 20° . 7 22' 23 24° Ace + Federal Reporters, Inc. 25 = “screening program isn't -- because multiphasic screening is /up, there's a recommendation for $2.8 million without a: ‘decision on the program 36, which is kidney disease, which is done in a lot of different ways. It doesn't always have to have a big computer. It @an be done with a small laboratory and one doctor. Well, again, I would recommend that we fund it and not call it a multiphasic screening program . DR. MILLIKAN: With this amendment? DR. CANNON: Yes, with the amendment that when this is finally decided it would be reviewed. So, if we now sum this requesting a quarter of a million dollars, because that's still in limbo; but adding a sufficient amount which is $107,000 to avi. take care of the beginning of the Stephens County program which would bring it to about $2.9 million. If you will accept that, I will move that the $2.9 million would be the appropriate funding. | DR. MILLIKAN: Second the motion. DR. CANNON: Per year. DR. PAHL: Is there discussion by the Concil? Dr. Cannon, the requested amount for that project 39 in the third year drops precipitously to $16,000, and I didn't know whether your motion basically was to $2.9 million for each of the three \ years or to reflect the requested amounts. DR. CANNON: In the absence of my portable computer, Ly 19 1 \ 16 7 18. 19. 20 e 21 | 22 23 24 Ace —Federal Reporters, Inc. 25. ‘thought that was pretty good, and so I thought if they went Seconded. Is there any further discussion? 52 I tried with my pen to tabulate the amounts that were deleted by both groups and I couldn't come up with $2.8 million. It wouldn't work out correctly. And I got within $100,000 and I $100,000 more than what they recommended it wouldn't be too bad. Now, if you can figure out a closer figure on that -- DR. PAHL: I'll take your portable computer. DR. SCHREINER: The point you were making is that the third year recommendation would drop off by roughly -~ DR. CANNON: $16,000. DR. SCHREINER: $84,009. DR. PAHL: The recommendation would be for $2.9 million for each of the first two years and the $1.9 million. plus the requested amount for project 39 for the third year. DR. CANNON: I think the staff could figure out these amounts and I think they know the intent of Council. DR. PAHL: All right. The motion has been made and MR. NASH: I have a question. Does your motion includ¢ the recommendations made by the site visitors and review committee regarding the other projects and the no funding recommended? DR. CANNON: Yes. That's what I went through. MR. NASH: With the exception of kidney. DR. CANNON: With the exception of kidney and the Ace +Federal Reporters, 10 HW 13 14 15 16 17 18 19 20% 21 22 23' 24 inc. 25° 12-1 53 exception of the Stephens County project. DR. PAHL: All in favor of the motion please say “Aye. ("Ayes") = r DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. DR. MARGULIES: I want to remind us all that because ‘we're still in the transitional period that these comments ‘in the form of recommendations and advice and so forth are ‘advice rather than requirements. I think we all understand that but I have to keep reminding us of that from time to time. DR. PAHL: Perhaps we could have our coffee break “now and reconvene. “|. DR. MARGULIES: One thing we do want to get done befor anybody is ready to leave is have any further consideration of. the review criteria which we discussed yesterday, so we may interrupt the review if necessary for that purpose to make sure that the majority of the people are here or as many people are here as there are now. (Recess) DR. PAHL: If we may come to order, I believe what we would like to do is return to our original agenda and take up the three New York applications starting with Albany. Dr. Brennan is not with us and we will call on Mrs. Wyckoff for the principal review. Ww 10 tr 13° 14; 18 17 —_ iO 20 r 21 22 23 24 Ace —Federat Reporters, Inc. 25 54 MRS. WYCKOFF: Albany seems to be in trouble. It had a review committee report sad. They seemed to be pretty irritated with Albany and. there's quite a management problem there. Both the review committee and the site visitors seem ° to feel that they desperately need the help of a deputy coordinator who is someone who can bring administrative ability into this situation. | This is atriennial application but the critique here seems to be centered around the fact that it's nothing but the renewal of ongoing projects with 75 percent of its activities within the core budget and most of its operational project money eaten up by the continuation of its two-way radio project which is something they seem to set score by that has 60 hospitals now equipped with this two-way radio system and a lot | of money is used to keep up this equipment and continue operation of this program. The hospitals are not yet willing they say, to absorb this and need three more years of time to do this. The review committee recommends that this Albany RMP be funded at $900,000 for one additional year, with a followup site visit in a year to check the region's progress with regard to numerous and specific recommended changes. Now, they have been very adamant about these changes and I think \ perhaps it would help if we put them into our recommendations so they have this leverage to work with. Ow ns Gos: 10 1} 13 144 15 i 20 ao. eo i 22 23 24 Ace + Federal Reporters, Inc. 25 55 The necessary changes are: (A) mechanisms for the phase-out of RMP support to be developed for this two-way radio and coronary training activity with the understanding that RMP funds will not be forthcoming for longer than 12 months and no more than one-year terminal support for coronary. training; that the RAG and its executive committee must become a policy-making body which actively review and evaluate ongoing proposed activities and they need education as to their responsibilities. They suggest that a conference seminar might be a way of doing this. That the planning and review sub- committee of the executive committee be composed of only executive committee members, now rather fuzzy being composed of staff and a lot of extraneous people that should not be voting on it, and that all deliberations of the executive committee must be reviewed and considered by the Regional Advisory Committee. ' “4 They feel that the functional review procedure needs to be straightened out. They have a situation where the present consulting groups, have been established to serve both technical review and program development, so that there has to be a means of separating these functions so that technical review people -- review is not performed by the same group that develops the activity. This igs a plain conflict of interest “4) situation. They also recommend that efforts be made to include 2 10 114 13 14: 15 16° oy 24 Ace — Federal Reporters, Inc. 25 ‘evidently has some of the same excellent data base collection 4 project be funded for only one year more for $900,000. 1 Council? , Albany is that there is hope that the recommendations of the 56 in the technical review process qualified people from outside the Albany and Albany Medical College area. Now, this area which has been going on in the neighboring region but it hasn't been applied -- the same problem. — They feel that strenuous efforts must be made to fill the core position of the nurse coordinator and they need a set. of operating objectives which are quantified and measurable, time dependent, and ranked in priority order. They also have some suggested considerations here which I think don't need to go into the recommendation, but which could be worked out by the staff. So, in view of this situation which I think ought to be discussed along with the other New York regions to see whethef or not there is a possibility of combination, I would like to move approval of the review committee's recommendation that this DR. FRIEDLANDER: Second. DR. PAHL: Is there other discussion from staff or A ‘MS, PAATZ. Well, I think what was important about site team which the review committee ditiopted are specific enough al ea \ that in a year's time when the site team goes back there's really not much question about what has to have been done as 5 10 1F 14] 15 V7 18 49 20 © 21 22 23 24 Ace —Federat Reporters, Inc. 25 il 57 there as there has been in the past. DR. PAHL: Thank you. DR. MARGULIES: i'd like to just add to that that these recommendations really should be supported by a good pit of interim effort on the part of the staff; and quite frankly, rf we are always in the uncomfortable situation regarding a coordinator and the kind of leadership he provides because we have a relatively laissez-faire actitude, but there seems to be no question about what's needed in Albany, as there will be in ‘some of these other programs, and I think we might be able to ‘supply a little more firmness to our concern over that ‘recommendation than a deputy coordinator. I think there are ‘other alternatives which we could suggest. MRS, WYCKOFF: Well, if they could unfreeze all the money they've got tied up in that two-way radio thing -- DR. PAHL: The motion has been made to accept the committee's recommendations on the Albany application. Is there a second to the motion? MR. MILLIKAN: Second. DR. PAHL: Any further discussion? DR. MILLIKAN: Did you want to hear discussion of the others before the vote? MRS. WYCKOFF: Do you think it would help matters to \ discuss the Rochester one before a final vote? DR. MARGULIES: I rather doubt it. I think there's 58 2 DR. PAHL: All those in favor of the motion please 3 say "Aye." ~ : 4 ("Ayes") 3H DR. PAHL: Opposed? Si ' (No Response) 7 DR. PAHL: The motion is carried. BF We will now turn to the Central New York application 9! with Mr. Friedlander as principal reviewer and Dr. Cannon as 10]| backup. t MR. FRIEDLANDER: Well, Central New York at Syracuse 121) has essentially the same problems it seems as Albany has for a 134 different set of reasons. I think while Albany has regressed, 14 we might say, I think Syracuse has sort of just treaded water 15 and done more of the same, but it's not really much of a sur- 161] prise. 17 It seems to me that the review committee's critique ce ~ Federal Reporters, 1Bii which really reflects the observations of the site visit team 19 really summarize what you find in reading the application. It 20' might be well to run through a few of these because they are 214 all reflected in the conditions under which the funding is 22} recommended. 23 The fact that the objectives are described in terms 244 of activities rather than anticipated accomplishments, this is Inc. 251}sort -- you get the vague feeling that they're talking about Vii not much that we can do now except look at each one separately. — \ Ace Federal Reporters, 10 Wy 12) 13 14 16 17 18 23 24 Inc. 25 the Regional Medical Program's committees, which consists ‘|primarily of physicians and little interrelationship existing 59 activities but there's no connection with accomplishments. They refer to the Regional Advisory Group as a viable entity with fairly good leadership. Iguess we get into some more of this middle-level kind of quality. Suffers from a lack of allied personnel, consumer representation, particularly inner-city and rural community, model cities, etc. The review committee believes that the Regional Advisory Group -- and I think this is also substantiated when you read the application -- needs to assume a greater role in giving leadership to the planning and operational activities of the program. They seem to be set aside from the program. It all seems to be project oriented and that the Regional Advisory Group has not assume responsibility for developing a regional plan. | The executive committee of the Regional Advisory Group, too, needs to expand its membership to include broader representation from low economic consumer groups, rural physiciay young activist physicians, allied health personnel, etc. The same problem exists here. And then the concern expressed over the membership of between those committees and indeed -- between the committees . \ themselves and between the committees and the health related groups in the community. They constantly refer in their summary A: 10 it @ 12 13 14 15 16 17 18 9 20) e 21 22 23 24 Ace ~ Federal Reporters, Inc. | 25 4 health activities in the area. of their activities of having working relationships with various - “recommendation that someone needs to be there to help the 60 of the community health related groups but nothing seems to happen. ~ The review committee also -- and I think with faint: praise -- the present core staff is good but small in number. Then they have the same problem here that Albany reflects, is th{s coordinator who's been there for quite a while but he's a nice fellow and if he got some help maybe they could move. It's a very similar kind of thing. Then the other criticism which seems appropriate -- this, again, is reflected in the recommendation -- the activitie UT previously funded by the Regional Medical Program have not been absorbed into the local health system with the exception of the 7} home health aid program. Now, in Syracuse, I guess the thing that's comparable to the two-way radio in Albany is the nurse education program, but this one seems to be an extremely good program but seems to be operating in a kind of vacuum for its own purposes and has no relationship to the -- or very little to the other allied The question of evaluation, you get this from reading the application as well, but you wonder about this. They have \ three evaluators and there's no relationship among them. There doesn't seem to be any interrelationship between the evaluating 15 ‘“ 16 18 4+there be a $200,000 addition to the current funding and that poor which appear to be two real priorities for the region. 7 lithe progress that's been made in meeting the conditions. 19° 20 q #4 @ 21 221 tw 4 23 24 Ace ~ Federal Reporters, Inc. 29 61 group and the core staff. They all seem to operate separate _ from each other; and also the fact that there are three part-timd¢ evaluators, three physicians who obviously have other interests in the community. But the region does express an interest in. evaluation but doesn't seem to be doing much about it. On the basis of these kinds of observations, it seems that the ten conditions under which the. recommendation is made. seem to be appropriate. The funding recommendation is that this $200,000 be utilized to develop activities that will help to improve delivery of health services to the urban and rural On the basis of this, I would move that the recommendation for one year funding of $850,000 with the listed ‘ conditions be approved, and also that the contingent on, as recommended by the review committee, a staff followup visit six months following the award of this application to evaluate DR. PAHL: Thank. Dr. Cannon? DR. CANNON: I support the comments given. DR. PAHL: The motion has been made. Is there a second? MRS. WYCKOFF: Second. DR. PAHL: Is there further discussion from Council or staff? 10 1 13 24 Ace ~ Federal Reporters, Inc. , 25 62 (No Response) ‘DR. PAHL: If not, all those in favor of the motion please say "Aye." rb ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. We now turn to the Rochester application, Dr. ‘MePhedran the principal reviewer. DR. MC PHEDRAN: The Rochester Regional Medical Program was site visited June 24~25, and the recommendations of ‘the site visitors were agreed upon by the subsequent review committee. Specifically, the recommendation was for this upcoming| 04 year $800,000, with this year only, and a followup site visit after that year. For comparison, the third year was $895,000 for a (12-month period. It actually nad been an 18-month period with ta funding of $1.45 million. The same problems of essentially no program but ll rather a collection of projects continues in this region. That >is, it's a problem that has been identified before. A site visit team in April 1970 -- and I think a subsequent management assessment visit, although I can't find that at the moment -- made the peculiar recommendation that a deputy coordinator be 10 VW 13 14 15 17 “48 19 20 @ 21) 22 23 24 Ace = Federal Reporters, Inc. 25 63 appointed to give the program direction and strength. It is |hard to view this as other than a poor substitute for an entirely new direction. Spme progress has been made, however, and even the conditions suggested in the critique on the blue sheet I think reflect the progress that was seen in the last year. For example, the second condition particularly, was that the region would have in this 04 year flexibility in budget rearrangment to build its core staff, develop a revised form of regional leadership, etc., and this condition was thought reasonable by the review committee because of changes in the region; for example, diversification of the Regional Advisory Group and improvement of that, and creation of an active executive committee of the Regional Advisory Group which appeared to provide increased strength for the program. Also, other hopeful signs were some objectives and priorities had been set and listed which wasn't the case before, and another asset was that the program had a good reputation with physicians and nurses in the area; but one wonders whether this wasn't to some extent because the program could be bent to almost anybody's purposes, at least according to the critique here. pevelopmental component was requested but specifically denied in the critique. , \ I move acceptance of the review committee's recommen~ dations of $800,000 -- I'm sorry, I left out one thing. ‘The 14 15 16 17 18 19 20 @ 21 22 23 24 Ace ~Federa! Reporters, Inc. 25 64 condition in the recommendation is that the kidney project is excluded from funding within the $800,000 level, but it's ‘stated that if earmarked funds become available there is no ‘objection to increased award of funding for this activity. This project, however, did receive an unfavorable review from the -ad hoc kidney panel and I wonder whether that is a wise recommendation. If the review was unfavorable and if the program is in difficulty, I'm asking for advice here, wouldn't it be better to suggest that that be left out unless -- and they ‘be discouraged from putting this into operation -- unless it would cripple the whole regional kidney program. I'd like to have some advice and help from staff and others about that. | DR. MERRILL: Is that kidney program in this yellow sheet here somewhere, a summary of it? | DR. PAHL: Mr. Spear, would you be able to give us any information on the Rochester kidney proposal as it was reviewed by the ad hoc panel? MR. SPEAR: I don't think it is, Dr. Merrill. DR. PAIL: Mrs. Silsbee has a comment while you're looking. | MRS. SILSBEE: Dr. Merrill, that application had come in the cycle before this one and the kidney eanel reviewed it several months ago before this application came in. The region \ \ at the time they submitted tHis application didn't know the fate of the kidney project so it was not included in this. 10 1 eo 12 i3 14 Ip 16 17 18 19 20: @ oon | 221 23 24 Ace =Federal Reporters, inc. 25 65 yellow sheet. _ DR. SCHREINER: I don't understand that. DR. PAHL: The description of the kidney project is not included in the materials before you at this time because it was reviewed earlier. I think the question that Dr. McPhedrai had was why did the ad hoc panel find this proposal unsatisfac- tory, an d then is this a wise thing to include it in the present recommendation. DR. MC PHEDRAN: ‘Mot exactly. I'm taking it as given that the ad hoc panel found it unsatisfactory, and I'm wondering why, if that was the case, why the review committee felt that if earmarked funds became availble there's no objec- tion to an increased award to permit funding of this activity. _ MS. FAATZ: The site team didn't feel very strongly about this one way or the other. They had the recommendations of the ad hoc kidney panel and the ad hoc kidney panel objected to this proposal primarily because it seemed to be a number of years behind the times. The site team, as I say, did not feel © strongly about it. I think the thinking was that perhaps if earmarked funds became available and there was nowhere else to put them -- it was a very wishy-washy kind of recommendation. DR. MC -PHEDRAN: Well, that's the way it seemed to me \ and that's why I wonder if we shouldn't -- I think we should exclude it. We should ga along with the recommendations of the — 10 a eo 12 13 14 15 16 WZ 8 19 20; ©} . 24 : 22 23 24 Ace — Federal Reporters, inc. 25° 66 ad hoc kidney panel probably. DR. SCHREINER: One of the comments that I've been making lately is this whole ad hoc kidney panel mechanism serves to really cut us off from the kind of information we got from the very simplified decision making. We have very little © opportunity to look over their shoulder. You know, “somebody left the program so somebody says the whole program was out, a $300,000 program and one man left the program and they thought it would collapse. I'm not sure that we're getting the input to review the kinds of things that we do want, a lot of things based on outside experience and the other people, because there's enough |. information here. I'm totally in the dark. They've got a good dialysis program up there if we could develop that in some way They probably don't have transplantation and this probably influenced the recommendation of the committee. DR. MARGULIES: I think your criticism is absolutely valid. We have not supplied Council or the review people at all adequately with the reports of the ad hoc panel.as to the basis upon which they made their decision or what their | criticisms were, and I think this has been part of the ad hoc arrangement itself. That's easily corrected, particularly now that we have that level of interest on the Council. I think we won't have any further difficulty with it. \ 4 16 Tt @ 12 13 4 15 16 17] 18 19 ~ 4 20 @ 2) 22 23 24 Ace ~ Federal Reporters, Inc. 25 67 DR. MC PHEDRAN: Well, r‘il just say that I'm in the _ dark about it and I just need somebody else to help me decide. MRS. SILSBEE: Dr. McPhedran, I think the reason why the committee was so wishy-washy about this is that if the kidney redevelopment was an agency by which the proader program could be brought together, then they would feel that that could ‘proceed. But they didn't know on the basis of the ad hoc panel's considerations. MR. SPEAR: Mr. stolof is at the mike and he was involved in the review of that project. | MR. STOLOF: I can speak only as was told to us by the reviews. The emphasis of the Rochester project which was a part of an overall plan to seek to strongly stress sharing and rather than procuring more organs they were sharing -- they were setting their mechanisms programmed around the international sharing of organs rather than stressing procuring more organs to be used. I think this is why the panel met with disfavor on the project and it felt that aue to the state of the art of the tissue typing they questioned the Rochester proposal because it was basing the majority of its sharing on tissue typing findings. | | DR. PAHL: Dr. McPhedran, do you wish to -- DR. MC PHEDRAN: Well, I just think I'll have to move \ adoption of the review committee's report, perhaps leaving in the third wishy-washy conditions, being unable to come to grips 68 1 with it any better than this. | 2 DR, MARGULIES: I think that since this is so unsatis- e 3\' factory, what we really should do is provide at least some 4 members of the Council, perhaps Dr. Merrill and Dr. Schreiner, 3\ with enough information so that we can come back and take ‘6 another look at this particular activity at the next meeting of ‘7 the Council because I think it's all out of phase and it's 8 vague and generally unsatisfactory. oT DR. MILLIXAN: Would you accept that as an amendment? 10 DR. MC PHEDRAN: Yes, I would. TT DR. MILLIKAN: I amend your motion. ©} 12 DR. MC PHEDRAN: You're amending my motion. I accept. 134 MR. MILLIKEN: Second the amendment. 147 DR. PAHL: The motion has been amended and seconded 15]| to approve the committee's recommendations and defer any 14] action until next Council meeting on the kidney project. Is “47 there further discussion on this motion? 18 (No Response) 49 DR. PAHL: If not, all in favor please say "Aye." 20 ("Ayes") © — 9F DR. PAHL: Opposed? 22 (No Response) 23 DR. PAHL: The motion ‘is carried. “94 Because Dr. Everist will have to be leaving before tdo Ace ~Federal Reporters, Inc. . . . . . . . a 25|,long, I wonder if we might skip to. the Memphis application with 10 1} 12: 13 14 15 16 17 1e Ace — Federal Reporters, 20 21: 22° 23 24 Inc. 25 69 Mrs. Wyckoff as the principal reviewer and Dr. Everist as backup reviewer. MRS. WYCKOFF: This is a request for $2,754,000 ae the fourth year of operation. They want $2.5 million for the ‘fifth year and $2.3 million for the sixth year, making a total of $7.7 for the three-year period. The current level of support is now $1,512,795. 1. They want authority for a developmental component in the event new funds become available. 2. They request continuation of 5 projects within the currently approved period, amounting toa total of $461,046. 3. They ask for $799,548 for core and $524,283 for continuation of 7 projects beyond the approved period. They want $969,356 for 12 new projects for each of three years. They will phase out three previously supported programs. There is a difference of opinion between the site visitors and the review committee on the amount recommended to the Memphis RMP. The site visitors recommended $2 million for each year, making a total of $6 million over the three years. The review committee recommended a cut to $1,627,000 for each of the three years, a total of $4,950,000. ‘The review committee cut core funds from $799,548 to $600,000. Then they cut all . \ projects, continuation, new and renewal, from $1,954,685 down to $1,027,000. The review committee's total recommendation, low 10 1} @ 12 131: 14 15 16 17 18 9 20° @ 1 | 22 237 24} Ace ~ Federal Reporters, Inc. 25° 70 as it is, is still above the current direct cost level of - $1,512,795. For those of yow who do not know the Memphis region, it is important to understand the extraordinary character of its composition. The RMP geographical boundaries cover portions of 75 counties in five states: Tennessee, Arkansas, Mississippi, Kentucky and Missouri. The area is a medical ‘marketing natural watershed. It is served by the University of ‘Tennessee Medical School. As you may remember, the original idea of RMP was that it would operate largely outside of the political sub- divisions of government and be designed to serve the natural groupings of wroviders, educational institutions, and voluntary health agencies. Now things have changed and RMP must cooperate with Comaxehensive Health Planning and other government agencies that are structured along the lines of political subdivisions. Memphis RMP has had a heroic task in trying to work out these relationships. Therefore, when site visitors and review committee and staff say that the organizational structure of Memphis RMP is "complex," “cumber~- some," and “complicated,” it must be understood that they are struggling with an anormously difficult provlem. When, for example, HSMHA issues a seemingly simply requirement that RMPs \ must submit their proposed projects to CHP for comment and review and receive at least an acknowledgement from them, in Ace -- Federal Reporters, + 10; 1}. 1 13, i4 16 16 7 18 19 20) 2% 22 | 23) 24 Inc. 25 71 Memphis, this means getting answers from five state CHP "A" - agencies, and innumerable "B" agencies, and then going to three HEW regional offices. = | On top of this there is the elaborate structure of the Mid-South Medical Center Council which is designated as the RAG for the MRMP. It covers 75 counties, has 156 members, 51 percent consumers. It is the grantee agency for the new Experimental Health Planning and Delivery System Contract with the National Center for Health Services Research and Development for $728,000. However, this body meets only once a year and if you will look at the chart at the back of the site visit report, you will get some idea of this unusual arrangement. I think you have that chart which may help you because this gets very complicated. The site visitors tried to find out exactly where the decisions were made and this was not easy. On paper, the Medical Center Board of Directors, consisting of 45 members elected at the annual meeting of the Mid-South Medical Center Council appears as the final authority for the RMP. It consists of 18 providers, 27 consumers, and is the CHP agency for 14 counties. This Board, which represents only 14 counties, meets ten times a year and puts its stamp of approval on the RMP proposals, which it receives from the new RMP Policy and Review \ Committee, a 36 member body of 28 providers and 8 consumers which meets monthly, and is appointed by the RMP coordinator. 23 ek i 24 Ace — Federal Reporters, Inc. 25 72 This body, on the other hand, represents 75 counties in five states and is a standing committee of the Mid-South Medical Center Council. Its chairman sits on the Mid-South Medical Center Council Executive Committee which is the policy making. body for the CHP "B" agency among other things. The site visitors questioned the legality of the RAG decision making process. I understand that that is now being put into a study. committee and that our recommendation that they go to the regional general council at ATlanta if found to be necessary. As it happens on a site visit when everybody's hair _ was let down, it developed that the real decision making seems to be nerformed by a small, very hard-working Planning Board which isn't even on the chart, but which is established to advise the coordinator. It not only screens all proposed projects for applicability, but advises the coordinator which applicants should be given core staff assistance in developing a proposal. This Board also meets monthly with the Policy and Review Committee. It has limited representation from the categorical committees. The core staff seems to have independent decision- making power almost equal to the Planning Board, judging by the large number of activities stimulated and conducted by them with little or no relation to the goals and objectives of RMP. They simply report directly to the coordinator. Actually, the coordinator is trying to fill two 10 nN 22, 23 24 Ace = Federal Reporters, Inc. 25 73 positions, himself and a much needed administrator. Both he and the core staff have been a little too eager to please too many ‘groups all at once. Core pas put in a vast amount of time ‘helping other health organizations to apply for funds only ‘generally related to. the broad goals of the Mid-South Medical Center Council and the RMP. There is a question whether the ‘cost of this is justifiable. Unfortunately, the coordinator seems to feel he can fill this large administrative void by recruiting an assistant for program development who is now coming aboard. The review. committee and the site visitors felt that much more is needed, and that the coordinator should hire a full time executive officer with broad administrative experience to carry on the day-to-day operations of the MRMP. One of the problems that concerned us is the obvious and documented need of the black population and yet the staff contains almost no black professionals. One example of this problem shows up in a beautifully designed physician continuing education program based on community hospitals. Practicing specialists from the private sector are invited by general practitioners to participate in advanced clinical conferences in which the patients of the inviting physicians are the subject of discussion. This plan is designed to serve a network of small and medium sized hospitals in the region, and has met with much success. But when I asked how many black physicians it on, oO = 10 1 13 14 19 20 @ 21 22 23 24 Ace — Federal Reporters, inc. 25 74 reached, the reply was "None." When I asked why, the reply was "Because the black physicians do not have the educational F qualifications to practice_in these hospitals." So the ‘dilemma was complete. In another situation staff pointed out that they had ‘achieved a big step forward by arranging for black physicians ‘to be allowed to visit their own patients in a Memphis hospital ‘even though they could not care for them. Review commitee and ‘site visitors agreed that an increased effort is warranted. The goals and objectives and priorities of the region fare stated, but the policy of accepting spontaneously appearing projects to please special groups has prevented the development of activities based upon the clearly identified needs of the ‘yegion. A nural sequel to this desire to please so many groups | ‘ig the not unusual tendency to pass on to the RKMPS and the ‘Council the unpleasant task of saying "No." ‘The region has not been able to phase out its support of seven projects after three years of operation. The decision to continue support is made without adequate evaluation of the effectiveness of the activities to date. The region is only now proposing to set up an evaluation orocess but in the meantime wants as much as 28 percent of the requested project funding for extending the life of these seven projects for more than three years. \ Both review committee and site visitors recommend that if Memphis RMP in light of its reduced budget still wisnes 10 11 @ 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace.—Federal Reporters, Inc. 25 limoving away from a medical school oriented staff and has good working relationships with medical societies, hospital associa- tions, health departments ,) CHP and other regions of RMP. It is to continue these seven projects, it should not be for more than one year. | | Among the new projects proposed is a request for $438,000 for Neighborhood Health Centers, Project No. 36. In it, Memphis RMP expects to act as a broker to put together a complete comprehensive health care package for four existing public health department facilities, expanding preventive services by implementing primary care. Their search for other federal funds has already been successful to the extent of $120,000 from NCHRD for the pediatric nurse practitioner training program which is a part of the package, therefore it” is recommended that the Memphis RMP not invest more than $318,710 in this project. Both the site visit team and the review committee felt that funds should not be provided for project no. 39 “Continuing Education for Physicians in Tennessee," a continuing education activity of the Tennessee Medical Association. It was felt that this could easily be financed through dues of members. In the final analysis and in spite of some of the negative aspects noted, the Memphis RMP has made progress in decentralizing and reaching out to broaden its base. If it can put its administrative house in order, it \ce~ Federal Reporters, 10 1 12 13 14 15 16 17 19 20 21 22 23 24 Inc. 25 / tions that are listed in the site visit report -- I mean, in you have anything. 76 has the potential of becoming one of the better RMPs in terms of addressing the broad issues in the provision of health care. However, I do not believe it is ready yet to be given authority for a developmental component . /I share the site visit team and the review committee's recommendation against it. I move approval of the review committee recommendation for a funding level of $1,627,000 for each of three years, or a total of $4,950,000, and I recommend the approval of sugges- the blue sheet. DR. PAHL: Thank you, Mrs. Wyckoff. Dr. Everist, do DR. EVERIST: Mrs. Wyckoff. has enunciated all of my concerns excepting one. I think the region has begun a series of efforts toward delivering health services, just as Stephens County is attempting to do in the program in Georgia. ‘These are all very good and they can't be faulted for their humanitarianis: and so on. But we just got over this in the 314(e) problem and we're going down that same path in some other areas, and I think we ought to be aware of this, and this very laudable group in Iuca County, Mississippi is an example of this. You can't fault it. It would be against sin or the flag. It's just \ delivering health services and nothing else. And the other thing is I think we ought to be 77 1|| concerned about this one of two or three multistate RMPs and 2\| whether or not they are really viable in light of the other ® 3!| programs that go along political lines. I think we just ought Alto be aware of it anyway; whether or not we make any policy 5} changes now is not important, but I think we ought to be aware 6|| of this. 7 This is a very difficult region to administer I'm ! Bl sure, with the kinds of difficulties -- it's amazing that they 91) get along so well with the contiguous RMPs, and they do 10}) apparently. They were all there represented from each of the . 11] four RMPs that impinge upon them. That's all I have. © 12 DR. DE BAKEY: I don't want to prolong this discussion 13] because maybe this isn't the time to bring it up, but I think 14) it's awfully important for us to continue to keep in mind and 15|| maybe to review from time to time what the main thrust of the 16|| Regional Medical Program is, and why is it necessary to establish 17||enabling legislation to do this job. 18] - I think it's important to go back and in a sense 19] recognize the history of its development and recognize the 2o;}intent of Congress in developing ‘enabling legislation and the @ 21 || amendments that have since been added to it. 22 In the final analysis, if this objective is being 23|| achieved by the funds which the enabling legislation provides, \ 94\)then I think it would be wrong for us to set up regulations Ace —Federat Reporters, Inc. . : : 25|\that would in a sense contradict that development. So I just 10 VW @ 12 13 14 15 16) 17 18 20 “si @ | 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 78 want to give you a word of caution about this because it's awfully easy to get set up ina set of regulations that really ‘handicaps you from getting.to your objective in order to Standardize a method of doing things. This is the only thing I'm concerned about in our discussions of these various regulations or policies that we -set up. Now, I know we have this policy on multiphasic screening and I think in general it's a good policy and I think, in other words, what we've done is desirable; but I think at the same time, if we find that there is a means to achieve an objective that is a sort of congruent with the objectives of the Congress in setting this up, then I think it's important for us to keep that in mind and not allow ourselves to get entangled with regulations or policies that prevent that from being achieved because there's always more than one way to achieve an objective. So, I'm very much impressed, for example, with a }9|, statement here that says that in the three-month period, yi January-March 1971, they had 1832 adults screened, leading to the detection of 1386 abnormalities. Now, here's a population that two-thirds of the adults there have abnormalities; one- third of which required referral to their family physician. \ Now, if you can tell me any other way by which this could have been picked up, some other means by which this could have been 10% 1] @ 12 13: 14 16 V7 18 19 20 @ 21 22 23° 24! Ace Federal Reporters, Inc. 25 79 done, then I think we ought to try and do it. But in the final analysis, this is one of the objectives of the program. : So I think, despite the fact that this may not fall within, let's say, the methods by which we want to achieve the objective, if it is achieving the objective we ought to do so. The second thing is that I realize that the future of this type of entity as a regional medical program may fall afoul of the political realities of the programs that may be developed in the future for funding, for interfacing with other programs, the fact remains that they do have something going right now that is reasonably effective, and I think that, again, we must be a little cautious about trying to change something that in a sense would jeopardize the efficacy of their achieving the objectives they're trying to achieve. Where we can help them, I think we should do so, and I think there are a number of areas here and recommendations being made that could help then, and the site visitors group has pointed these out, and I think with good will they could do it. DR. ROTH: I had one very small comment or question — on a very minor point in Mrs. Wyckoff's report. There was one ‘project in which it was recommended that it not be funded because -- and I think I quote fairly closely -- that it could \ easily pe funded by the medical society from members' dues. MRS. WYCKOFF: Yes. 10 tT 13 14 18 16 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, !nc. 25 of the New York State Medical Society dropping their membership ‘our prerogatives in RMP in telling medical societies what they. 80 DR. ROTH: I wondered what medical society had to _ say about this, recognizing that members dues in medical societies are quite a problem these days with all levels increasing and I don't know what the situation is in Tennessee, but a recent dues increase has had the effect of 9,000 members and I don't think that RMP wants to take, in effect, a project. which alienates physicians from cooperation in good programs. It's a very minor item but I wonder if we're exceeding ought to spend their dues money for. MRS. WYCKOTS: Well, I-think perhaps they felt that the relationships were very good and solid with the medical society there and that if they pride this program very much they might be willing to put up -- they were willing to risk it anyway. 7 | DR. ROTH: Normally medical societies, as I'm sure this Council understands, are not funding agencies of projects of the type that RMP deals with. DR. EVERIST: I have just a brief comment on that, Dr. Roth. This was supplying an extra person on the staff of the medical society which I think is justified, but I think you're perfectly right that we ought to delete our comment. DR. ROTH: It would be fine if it was the other way around, if the medical society said that it could cheerfully Ace +Federat Reporters, +4 10 VW 12 13 14 15 16 22 23 24 Inc. 7 81 absorb the project. | | | _ DR. EVERIST: I think it's an inappropriate comment. \ MRS. WYCKOFF: De you need a motion to delete that comment? DR. PAHL: We'll accept that as consensus of the Council as an amendment to the motion. Dr. Hunt, did you have a point? DR. HUNT: Yes. I'd like to endorse Dr. DeBakey's statement relative to the screening process. it heartily endorse screening facilities and screening processes as long as they're productive, but it's my understanding that the objection was that we were a little tired of the "DUDAD" (?) development stage to the point that we were spending millions of dollars to. develop something that a couple hands, eyes and ears could do very easily, and that this was the part that we were a’ little bit discouraged about and that if the phasing screening process llcould get away from the multiphasic screening -- get that word out of there, and just call it screening process, that if it's iproductive and it's bringing medical care to a group of the licommunity that hasn't got it and needs it, then we're for it, fiand we'll fund it. DR. DE BAKEY: Another example, for example, in the Georgia grouv, where, of course, they've had a longstanding , \ interest in hypertension and there's been several studies which have clearly demonstrated that a great majority of hypertensives ab 23 24 Ace — Federal Reporters, Inc, 25 +h 1+ studies that came out from Frieze clearly demonstrated even 82 in the United States, and there are some 20-odd or more million people in the United States with hypertension, go unrecognized. ‘And they pointed out in the study that they did just the simple ‘W’screening city that they did that -- it wasn't multiphasic 'screening -- 28 percent were undetected requiring treatment. "Now, I think this is important. Here's a disease in which there's no better example ‘of the objectives of the heart disease, cancer, stroke program ‘than hypertension, because here's a disease in which there is. ‘sufficient knowledge available at the present time to be able | ‘to effect a significant impact upon its control and upon St mortality and morbidity. There's no question about that. This thas all been very well demonstrated and just recently in the ‘moderate hypertension requires management control if you're going to affect mortality and morbidity, and there's no question about the fact that you can do it and there's no question about ithe fact that drugs are available for this purpose. So all we need to do is to bring this to the people who have it. This is really what the whole program is about. This lis the basis for it. So if you develop a screening program that can pick up hyvertensives in an effective way and really bring them in and provide good management control for them, then we . have accomplished a significant thing so far as this program 1s concerned. This is what we want to do. Now, the mecnanisms by 10 ne 14 15 16 17 18 19 20 @ 21 22 23 24 Ace=Federal Reporters, Inc. 25 83 which we do it seems to me is important only in determining the efficacy. That's all. DR. MARGULIES: Well, the question of screening is one thing, of course. The question of multiphasic screening is ‘noather one. DR. EVERIST: And the delivery of health services is another. DR. MARGULIES: Yes. If you look over the document ‘on which you made a decision last time, you'll find that we ‘have millions of dollars invested in multiphasic screening ‘around this country just in the RMPS activities and there are many more in others. Whether or not they are serving an effective function for screening purposes is open to doubt and ‘for the most part I'd say they haven't been. Now, if you want to screen hypertensives for the cost of one multiphasic activity you could screen hundreds of thousands of hypertensives, seb up programs, and do something ‘about it. And if the Council wants to change the policy in the | direction of multiphasic screening because this is the only way in which you get screening, it, of course, is free to do so; but ‘I understand that that is not what you're talking ‘about, Hike, at all. DR. DE BAKEY: That is not what we're talking about. _— \ DR. MARGULIES: What we need is simplicity in screenin | effectiveness in it related to continuity of care and related \ce ~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19) 20 21) 22 23 24 Inc. 25 84 to the high risk populations. And the hypertensive is a very — good example. But the multiphasic effort, almost in every instance, is associated with some enchantment with a gadgetry which is ' involved, and a tremendous diversion of effort into something © which produces relatively little in the way of patient detection and care. I think we need to differentiate carefully between - one and the other. It would be interesting to know what they could have done in that county without a complicated mechanism with an effective screening process. Perhaps it couldn't have been done. But if we're going to get good screening activities, I think we have to lean away from the multiphasic and look more. in the direction of simple screening of the kind that you're talking about. DR. DE BAKEY: I think another factor to keep in mind is that it depends -- that one of the important factors in all of the screening processes, whether it's multiphasic or more svecific and simple forms of screening, it's related to some extent in terms of the population that's being screened. Now, obviously, in this area, we're dealing with a population in which there has been little or no medical care over a long period of time and, therefore, no matter what you screen in that \ area, you're going to screen a lot of abnormalities because they haven't had the care they should have. 10 1 © 12 13 14 15 16 17 18 20 ee. 21 22 | liwhen I voted against the computer thing, was whether these were 23 24 Ace ~ Federal Reporters, Inc.. 25 So if you do multiphasic screening in which the people there had good -- you know, beginning with prenatal care and ithave had good care all long, then the percentage of results is going to be extremely small in terms of abnormalities; and perhaps the whole process will become less efficient and, of course, economical. But any kind of screening in a population in which the medical care has been bad over a long period of time is going to be worthwhile. DR. SCHREINER: There's another side of the coin now. I think we've gotten ourselves into semantic difficulties because what you're really talking about is a detection program for hypertension which is a very, very valid thing; but if a | region has nut together -- to bring people to a storefront or bring a van to some people -- then it may be very much more efficient actually to try to detect many multiple things rather — than just try to detect one thing. In other words, the added cost to obtain something on that model might be relatively small, and even though the yield for those other detection programs might not stand up lin their own right, they might stand up very well as a supple- ‘iment to a hypertension detection program. I think, at least what I thought I was voting for \ firandom data collections by questionable methods of very, very high cost. The Public Health Service is spending almost a 10 it e° » 13) 15 16 7 18 19 20 @ 21 22° 23 24) Ace - Federal Reporters, inc. 25 ‘million dollars locally here to develop a computer program for — ‘dollar ven. rus to keep it in mind because we're not accustomed to having 86 writing admission notes on patients. The way it works out, you go through a questionnaire, you return the questionnaire to a clerk and the clerks puts it on a key sorter card and the key sorter card computerizes the chart. That's a half a million DR. DE BAKEY: I agree with you. I think though, there's one other thing to keep in mind and it's difficult for this reponsibility, but you will recall that the heart disease control and other disease control programs that used to be in an entirely separate agency were transferred to us and they're supposed to have transferred the money. Of course, that's just. a real shell game because what it meant was that the money had | disappeared but we have the responsibility. So there is no other control program, virtually, except that which resides, in a sense, in this agency for these areas. The National Institutes of Health don't have them either. DR. MARGULIES: Well, I think the decision which was made last time really said only one thing; that we think that there is potential merit in what we're doing but we don't know what the merit is and what the best way is and under what circum stances, and let's not spend more money until we can get a few \ answers. I don't see any readiness to change that. Of course, Dr. Everist's point still remains valid and wo BM & Or 16 1 14 15 17 18 19 20 @ 21 22 23 24 Ace> Federat Reporters, Inc, 25 87 it's a troublesome one. We've dealt with it many times in this Council. ‘That is the responsibility for delivery of health “gare is something which could absorb all of our funds and get us into no end of difficulty, particularly is that true when ‘what you're supplying is desperately needed and you can't back ‘out of it, and we're eating up most of the national budget in ‘trying to meet exactly those kinds of demands to pay for ser- ‘vices. DR. DE BAKEY: Well, of course, again, if you go back to the law, you will see that we are discouraged from doing ‘| that, very definitely. So that I'm not sure that we would be on very good legal grounds spending money for just delivery of health care. Now, this has to be in the form of demonstration and that sort of thing, and that's what I think we're trying to do. DR. PAHL: The motion has been made and amended. Is there a second to the motion, which primarily is to accept the ‘recommendations of the review committee together with the snecific points relative to the individual projects and deletion of the reference to the medical association dues for project 39.) MR. MILLIKEN: Second. DR. PAHL: The motion has been seconded by Mr. Milliken. Further discussion? (No Response) DR. PAHL: All in favor of the motion please say "Aye. QO so aN tO eel 2& Vy e 3 7 _ f : oll ib Oa) Z 18 12 20 r 21 | 22 23 24 Ace ~ Federal Reporters, Inc. 23 88 ("Ayes") DR. PAHL: Opposed? (No Response) = DR. PAHL: The motion is carried. MRS. WYCKOFF: This does not knock out the multiphasic project you understand. That is, it's up to the RAG to decide how they're going to redeploy these funds. DR. PAHL: Before turning to the next application, I think we would like to request your attention to the sheet of paper that.we handed out to you yesterday relative to the review committee's overall ratings and rankings of the appli- cations which we've been reviewing, and although we haven't gone] « through the entire listing because there will be some additional 4. departures as a result of other plans, I believe it's important _ to us to have a sense of the Council relative to this new pro- cedure. please understand this is still on a trial basis. We do intend, unless you feel it's completely inappropriate, to improve and utilize it again for the next round and we believe we will be able to bring better information to both the review committee and to the Council interms of the rating system. But we would like to have whatever comments you would wish to make at this time relative to your feeling as to how well the committee reflects your thinking on the applications or any other comments that you might have relative to the presentation 10 11 @ 12 13 14 15 16 7 18 19 20 21 @ | 22 23 tb. ¥ 24 Ace.= Federal Reporters, Inc. 25 /"A" group; and yet, as I recall the mathematical model, there {| area. j/a rating system does where you're trying to transfer opinions to numbers, I think it's a pretty good one. But I certainly | give to a program with the feeling that I have right now, that 89 yesterday and further thoughts. DR. ROTH: I assume that in the further modifications that this will be taken into consideration, but it appears to me that we have done an awful lot of talking about the competenc of leadership, the impact of an individual on a program, and another thing that this roughly manifests is that where you have strong leadership you have good programs which get up into the was no real way that you could directly put that consideration in. DR. PAHL: That has already undergone modification in the sense that the organizational viability and effectiveness criterion has now been separated into separate items for the coordinator, core staff, regional advisory group, and grantee institutions; so that there will be separate ratings for those four items and I think that will provide the committee and the Council with greater opportunity to express preferences in this DR. HUNT: My feeling, relative to this, is that as would feel that in the future I would interpret the number you it's an almost impossible task to transfer the various ideas that we have relative to a program to a single number; and I 10 1 @ 12 -13 14: 15 16 17 18 19 20 © 21 22 23) 24 Ace — Federal Reporters, Inc. 25 90 think these numbers as you show that they're weighted -~ really,_ I would rather rely upon the English language to describe a program rather than a number because I think it's going to bring back to me something that I -- the interpretation that's given here, for instance, by the site review and by the review: committee. I guess what I'm saying is I don't understand why we. have to transfer the English language to a number. What is it to be used for and what's the motivation for it? It appears to me we spend an awful lot of time and money trying to do this and I commend the effort, but I just wonder if we're trying to_ do something that high school teachers have found almost impossible for the last 50 years, and that's trying to get a different grading system for students. DR. PAHL: Before responding, maybe we can have additional comments which bear or extend that observation and then we will try to respond. DR. WATKINS: On the same topic, it would seem to me, looking at the chart "C", it puts New York, Albany, Central New York and Rochester on the lowest level of the totem pole. I. wonder if it has a significance. To me, it doesn't seem to qualify New York to any place in the program when you put it at such a level and in New York we feel very proud of the job that we are doing in New York. DR. KOMAROFF: I'm impressed that the numbers really 10 1} 13: 14 154 17 18 194 © 214 22) 23 24: Ace =Federal Reporters, Inc. 25 ftsomething to your opinion to weight it and give people a prief why. At that point your English comes into play and you can say with it. If one gives it 2 and the other 12, at that point you 91 do nothing more than substantiate or tend to substantiate the - accuracy of what we think are intuitions, but I think to spare ourselves some outside observers feeling that decisions are arbitrary that it's easier to defend, particularly in the time of fiscal stringencies, easier to defend the allocation of funds when you attach numbers, granting the artificiality of it. NIH does it and most health funding agencies do it and I support it as a generality. DR. MERRILL: I think my experience with this kind of system would lead me to believe that both things are possible;- that what you're doing with the numbers here is simply giving summary idea of it. If, for instance, goals, objectives and priorities has a score of two, that will ring a bell and someone can ask you it has a low priority. Otherwise, you have to write 28 pages, each one of which describes a figure. If you have five reviewers and they all give it 12, then lI think most people would agree have your discussion and pring out your difference. I think this is simply a shorthand method of doing that and I approve of it. MR. MILLIKEN: I would add to what Dr. Merrill has indicated here, that I think the rating system is not an end in 15 14 17 24 Ace — Federal Reporters, Ing. 25] ‘system which shows where the weak points are, where the other 92 itself. It cannot be. On the other hand, I think it's _ exceedingly helpful to this Council to have worked out a rating kind of judgments must come in in terms of dealing with each individual application. So, in that sense -- and I felt yesterday the comments generally from other Council members supported the fact that this should not be an end in itself; that the total ratings of these scores are only for further judgment by this Council. That end, I think, is very worthwhile. DR. PAHL: Thank you. DR. SCHREINER: I'd strongly recommend the reading of the editorial in the current weekly edition of Time Magazine, which is entitled, "Imaginary Numbers," and it points out the - psychological traps for numbers, for example, that are accepted widely in publications and in Congressional hearings and on other official data, and how difficult it is to unnumber a number once it is established. For example, everybody will quote the dollar value of goods stolen by heroin addicts in New York City and I've heard it on three TV programs, and then somebody took the trouble to investigate how it was arrived at and it turns out that it's in excess of all thefts that pecue in New York City; and, of course, it couldn't be reall to arrive at that.’ But it got embedded because it was a number and it now has become a fact 10) it @ 12 13 14 15 16 17 | 18 19 20 © 21 22 23 24 Ace ~Federal Reporters, inc. 25 ' How you arrive at a number; whether the number has any validity it was a very useful exercise to go through this to see whether “or not a weighting system could be developed that appears to ‘agree, at least in one instance, with the overall general “approach in the English language. In that sense, it leaves me ‘reasonably comfortable; that at least there hasn't been any ‘bizarre weights put on the value. As an experiment, that's ‘tion of it. Once you get something down into a number, then the| ‘more simplistic people are, the more they will approach that 93 or mistaken for a fact. , | _ It seems to me there are three things to analyze: and usefulness; and then how you interpret the number. I think good. I also see the shorthand value of it, as John has pointed out. What I'm really worried about is the interpreta- imagin xy number as a fact; and if we're concerned with -- instead of trying to help Congressional relations, we'd be worsening it by giving it some artifacts really which can be - seized on and which are going to be given a kind of permanence that they really don't deserve. So I'm really more concerned not with how we arrived at it, which I'm happy about; but what's going to happen to it. MR. FRIEDLANDER: Following up on what's going to \ happen to it, I think it all depends on who's interpreting it. If the ratings given here are to be used by the Council, I think 10} 11 eo 13 14 1Si} 16] 17 18 19 20 © 21 22 23 24 ace ~ Federal Reporters, Inc. 25 ‘are either succeeding or not succeeding; they are good or they are bad; and the "they" is really a collective singular noun. “his has never been true. This is one of the hardest things “in terms of interpreting Regional Medical Programs, that we've ’ had. Services acknowledges the fact that there are variations in the including the Congress -~ I think this is really facing the ‘reality and I think it's going to help the Regional Medical defensive purposes. They will be used so that we can, when we 94 this is probably not the most effective way to effect its - purpose. But I think this kind of rating system will serve the purpose to dispell a misconception that's gone on about RMPs for a long time, namely, that Regional Medical Programs Now, in all honesty, if the Regional Medical Program quality of programs and publicly acknowledges this, --public Programs collectively and separately to know this. Now, it's going to be a sensitive point, no question, in each of the various regions, particularly those that wind up in the "Cc" category; but, again, it may be the motivation to move upward. DR. MARGULIES: Well, I think the thing which concerns| you mostly, as I understand it, is. what use will be made of this kind of a numerical system. And for practical purposes within the context of our usual function, they will be used for \ are asked to give evidence that we have made an analysis, have 95 1|} something which someone can look at very quickly, as you have 2\| indicated. Now, if they want to know more about why there is @ ‘3ila-difference between Albany and California, then there will be 4|| ample evidence which can be all the way from this Council 5\ meeting on back to the life history of both of the Regional 6i| Medical Programs. ? You may recall that in April of this year when there 8\\was a funding cut, the only kind of decision which seemed to be 9} tenable -- and this was a political decision; it was not a 10}| programmatic one -~ was an across-the-board cut which affected 11] everybody, which means that it did not affect everybody @ _ 12'jequally; it affected them very unequally. For example, there 13|were programs which had unexpended funds, which ended up as a 14") result of the cut, with having slightly less unexpended eunds. 15] Others which had budgeted well, managed well, which were 13] severely damaged. Now, what appeared to be a very even act was 17|a very uneven one. T8}- | We are dedicated to the concept that we should invest 19] puolic funds where public funds will benefit the public, and o)\when there is a disparity in the ways in which programs can @ 21 meet public needs, that should be reflected in the way in which 22 |) we expend our money. 74 I don't believe that this numerical system is going to . \ 24}help this Council per se. I think it will help greatly, however, Ace = Federal Reporters, Inc. 25 look at those figures which Ed has just laid out, it might be a way of simply diverting what energy there is in the RMP into a big proposal which is attractive. DR. MERRILL: I think, speaking as perhaps the last remaining kidney expert here, one of the problems that's —_ 10 ik e » 13 14 15 16 17 - 419 20 22 23 24 Ace ~ Federal Reporters, inc. 25 |) the need of the D. C. area in transplantation. 119 represented by this proposal has already been touched on, the — fact that we don't have the figures for someone who's spent a lot of time in transplantdtion and dialysis, and I can make nothing whatever of the summary, nor, unless I know the exact capability of the Veterans Administration, can I comment upon the feasibility of the Veterans Administration alone handling It's been mentioned, for instance, there are other areas in which they're doing transplantation. The Army and the Navy have been quoted. The head Army transplanter you saw on the vhotograph taken in Watts. He's now in Watts. And the Navy transplanter was in the Holiday Motel the day before yesterday on his way to Tulane. | So these are the kind of figures I think we need, along with the number of patients on dialysis who might be suitable for transplantation, and also the tissue typing facilities; there are some problems about that. I would like to know, if I might, about the establish- ment of a community home dialysis training. Does this mean new bricks and never or does this mean new funding and operation and on-going operation within a hospital or several hospitals? This would be important. I. think that probably the Washington area does need ; a coordinated dialysis and transplant center and I think the suggestion that people get together on this is an excellent one, “A. 10 1 18 19 20 @ 21 22 23 ‘ean promise you -- in this or many other areas. And I would ‘eatalyst. I think, having been there, that's a very good point. lout, so that they are aware in the District of Columbia of what slibefore this discussion is over. ,||reverse, because as a site visitor I rejected an ambulance 24 ce — Federal Reporters, inc. 25 120 and in spite of the fact that money tends to be a dirty word, there is no greater catalyst for cooperation than funding-- I think that if it is within the scope of RMP to suggest this and implement it, it would be well worth doing. DR. HUNT: If somebody will name the figures and get them together, I'm willing to recommend it, if that is the DR. KOMAROFF: Do we have to name a figure or just indicate our sympathies for a revised proposal along these lines? DR. MARGULIES: Well, there is an interesting grape- vine in the kidney area which I suppose must be associated with the number of tubulars which are available, but somehow, whatevet action we take is well disseminated before it's even been typed attitude this Council has.-not yet expressed but will express DR. HUNT: I might tell you that doesn't work in program that was recommended by a local Congressman and, by God, I heard about it, but after the fact. DR. MARGULIES: Yes, I know about that, too. I think if this Council came to the conclusion that the proposal is one which requires an extraordinary kind of review from the technica] ice +Federal Reporters, 10 it 12 13 14 15 16 17 18] 19 20 21 22 23 24 Inc. 25 121 point of view, from the Regional Medical Program point of view,- an effort to try to resolve differences, and was willing to ‘reconsider it then after that kind of further discussion, it would be a good idea. I know that we've already had the review and I know there have been all sorts of actions, but they have’ been inadequate to this extraordinary circumstance I think. Matt, does this seem reasonable to you? MR. SPEAR: I think that!s very good. DR. MARGULIES: Bill, I think what you were talking about in your presentation is the way to proceed and we don't have to attach any money to it, but rather let them realize that there is something which can be done if they'll make sense. DR. HUNT: Well, if there's such a thing as planning ‘funds, I think they should be made available. MRS. SILSBEE: We did that before. DR. HUNT: We did that in the screening process programs here I know. DR. MARGULIES: I think what you can do, if you want to, is disapprove it but give them the opportunity to come back with a better vlan. DR. HUNT: I think that's a pretty harsh treatment here because they're really suffering down here. We did that to them pretty badly last year on their general program and I would rather hold their program in abeyance pending a rereview after the site visit of the ad hoc panel and local interested 10 ie @ 12: 13 14 15 16° 7 18 19 20 @ 21 | 22' 23 24: Ace —Federal Reporters, Inc. 25 122 - individuals, so I would move that. DR. PAHL: Is the motion for deferral and reconsidera- 1 tion after site visit and-supplemental material becomes ’ t available? DR, HUNT: Yes. DR. ROTH: I'll second it. DR. PAHL: The motion has been made and seconded. DR. HUNT: Consultation and site visit by the ad hoc committee? | | : DR. PAHL: Yes, by staff and the ad hoc committee. DR. MARGULIES: They come in for a full review in November so this will work out all right. DR. MERRILL: Is there any real advantage to having this proposal renegotiated, or rather what really needs to be done, having a brand new proposal based on some sound advice from people who know what we want to do and submit it?, DR. HUNT: That should -be part of the recommendation I think. MR. SPEAR: You know, the panel wasn't terribly disappointed with the application if they had pursued the point of providing a out for their dialysis patients with trans- plantation. The comment was made, “If they would just do one center, give some egress from dialysis, we could approve any one of the dialysis projects. Without this egress, something to add on to the backlog, there was no merit, so the application “10 it @ 12 13 14 15 16 17 18 Z 19 20 @ 21 22° 23 24 \ce = Federal Reporters, Inc. 25 123 contents were not totally without some usé. _ ‘DR. MERRILL: Would that require, then, simply revising the original proposal to add transplantation or would it -- it seems to me it would require considerable revision to it in terms of tissue typing, availability of centers, inter- unit and inter-hospital cooperation and a good many other things} ‘I think these things would have to be spelled out pretty carefully. MR. SPEAR: This might well be done. One of the concerns was who has had a hand in planning the project that came in, and this was one reason that it was specified that it was desired possibly that the chief surgeon, chief of medicine, and chief pathologist at each of the institutions be at such a meeting. DR. HUNT: I would amend my motion to include that. That's a very important point because it speaks to a relatively important part of this problem. MR. VAN WINKLE: I would like to point out that the planning goes back in the District to my knowledge at least five years, and we did meet with representatives of all of the medical schools, all of the interested parties, the district health denartment, and there was planning money made available by the City Health Commissioner at that time, I think some $40,000 or $50,000. They assigned a resident full time to develop the planning on this. They met with us repeatedly. 10 WV . » “13: 14 (15 16 V7 18 19 20 @ 21 22 23 24 \ce-Federa! Reporters, Inc. 25 “young physician who was in said, "I fully understand what you'ra ‘wasn't for this 'tie' situation." He says, "I'm not permitted -to do so." And I don't really think that just going back and ‘yeplanning -- it's been planned to death. ‘advice again. I can say that advice was not followed. And the 124 This has been going on on a continuous basis. This is the - second proposal that came in. They did come back to us for speaking about; I understand the need; and I could so do if it They're going to have to recognize what their problem } is, and the problem relates to the patient who needs the service, and I think that's what they're going to have to address themselves to. Now, I'm not sure -- I have even suggested that. perhaps it should be a directive effort and perhaps we should go in there and do it through the contract mechanism, Dr. Margulies, rather than through the grant, because at least you can be directive in terms of placing emphasis on what should be done. DR. HUNT: I don't know whether this is the time. I was going to address myself to this later on. But this problen, in a different form, it seems to me, has come up on every kidney proposal that we've talked to in one way or another. It appears that we have set up rather strigent regulations and directives relative to a categorical disease that we're having a lot of trouble getting them implemented. We're having trouble \ee = Federal Reporters, 10 VW 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 ‘tative -- what you call the contract approach -- to handle it.- finding the people and it's expensive. _ As much as I abhor authoritative medicine coming down from up above in the "Big _Daddy" approach, I sometimes feel that maybe that this is what we ought to be doing here, because we'ra . getting into a very, very expensive facility and we know that most of the 55 programs in RMP can't fund a thing like this and carry it on locally after we get it started; and therefore, I think -- and this is a facility that we're not providing in our health care picture throughout the country -- therefore, this is the time and place, I think, for public authority to step in and say, "We'll provide this." And I think if we do this, then we can fit the plan to suit our own regulations, and what we're trying to do right now is set up a bunch of strict requla- tions that are going to cost a lot of money and we can't find th people to do them. So I wonder if we shouldn't give some thought to whether or not this isn't the type of health problem that is national in scope, and we have a capability, limited as it is, to handle, that we shouldn't use a more directive and authori- We can't establish transplantation centers in all 55 Regional Medical Program districts. There's no question about that. And I think our job is to provide the facilities and we have to get the patient to the facility. I'm even concerned right here in discussing this, when Cb. 10; 1 @ 12 13 14 15 16 17 "18 19 20 @ - 21 22 23 24 ce — Federal Reporters, Inc. 25 ‘have to look at the geographical area and if it's logical for | going to have to bring the patient to the facility. i the help of the local RMP program to implement what is handed 126 I learned that Virginia has their own transplantation facility - and it's not too far to Virginia from here. So that I think we two or three RMP programs to joing together to solve a program I think it's logical for the advisory committee to recommend that in contiguous areas we will set up the facility but you're I strongly encouarge the use of volunteer help and dwon from above. DR. MARGULIES: I think probably what we need, 1f © may suggest it, is again -- and we haven't done this in quite a while, and not in quite the form that I'm going to suggest it -- is to use a portion of the next meeting of the Council to bring i us a little more up to date on what are the problems interfering with the development of these kinds of facilities; because they are only partially those that you've identified. Certainly, one of them is the availability of competent people in a field which has advanced very rapidly and in which the expectations have exceeded facilities, individuals ,| skills and so forth; and I think it would be most appropriate if the Council did have some time next time around on tnat issue. Because the ad hoc committee has been uniformly ~-- not uniformly, but very frequently and overwhelmingly disappointed with the kinds of proposals that it's been reviewing, and if 10 VW © 12 13 14 15 16 17) 18 19 20 4 ) 2) 22 23 24 Ace ~~ Federal Reporters, Inc. 25 127 that's the case, then we have a responsibility of trying to decide when then do you do about it; and there are a variety of ways in which we could approach it. DR. HUNT: I would just add one personal experience’ to this to get my point across. There has been -~ one of the proposals that we had here from the Foundation is a disseminatio of knowledge program. I can tell you that that can stimulate some pretty good problems. attended, as a public official, a meeting relative to the health problems in our county in Western Pennsylvania, and as a result of an advertising program and calling attention with scare mechanisms about the number of people that are dying because they don't get dialysis because we don't nave something to take. care of this person, we had a massive influx of people that wanted kidney transplantation and dialysis facilities in every hospital in Allegheny County. This is the kind of misinformation and hysterical information that we can get out, and it's wrong for various agencies to carry on this kind of a promotional agency without knowing what they're doing. We can avoid that by taking the bul "}by the horns and deciding what should be done, as much as I abhor that type of approach in other cases. DR. PAHL: I'm afraid that my blood sugar is low and I would like to have someone please rephrase what is the - Council's motion. Is it for disapproval with staff assistance _ ar Los Federal Reporters, 20 21 22 23 24 Inc. 25 129 If they're not able to do as we suggest we may have to come back and say it didn't work. DR. MERRILL: Just one other question here. Whet is the grantee for the application? Who is the grantee here, the applicant institution? DR. MARGULIES: It's the RMP, the District Regional Medical Program, so it would be in that setting that the dis- cussion would take place. | MRS. HYCKOFF: Isn't it important who convenes this group, whether you get cooperation or not? Wouldn't it be a good idea to arrange that the convenor not be the one that was © doing it before? DR. MARGULIES: Well, I think that what we will have t do in this case is make it an RMPS issue, rather than a kidney division issue alone, and it would be the RMPS to the RMP with. the kidney issue and the RMP involved, so it's going to be a major kind of discussion. MRS. WYCKOFF: Yes . | ‘ DR. PAHL: Is there further discussion? (No Response) DR. PAHL: If not, all in favor of the motion please ; ; say "Aye." ("Ayes ") DR. PAHL: Ooposed? (No Response) VY 10 ni @ 4 13 14 15 16 17 18 19 207; . 7 22 23 24 Ace ~ Federal Reporters, Inc. 25 LZgA DR. PAHL: The motion is carried. _ The next application is New Mexico with Dr. Schreiner aS principal reviewer and-irs. Wyckoff as backup reviewer. DR. SCHREINER: The New Mexico application and the “review makes two excellent points; one is the value of a good ‘site visit and the other is the power of the DeBakey principle, "Send me the money.” I went out on this site visit and I believe Tony did too, and he may have some additional comments which I would welcome. My own impression, having been on a lot of site visits, was that it was a rather unique response to the site visit in that the response started happening while we were there, and as the very early interplay came out between the / site visit committee and the region they not only accepted some of the things but they began to do something about them right on the spot. I think this was also significant and borne out in the letters and literature which has come in subsequent to the site visit which shows I think some very constructive turn of events. The power, the money, just to put in perspective, my computer here comes up with an imaginary number which that for Illinois we're spending something like 10¢ a person, and for Texas about 15¢ a person, and for the New York State Regions about 50¢ a person, and that we've been spending in New Mexico roughly about a dollar a head. A. 10 11 © 12 | 13 14) 15 16 17 18) 19 20 @ 2) | 22' 23 24 Ace -— Federal! Reporters, Inc. 25 ‘iwhich we have stressed the importance of. The coordinator here ‘on the one hand; on the other hand, he did have a remarkable 130 Now, this has more than that figure would imply in _ terms of its impact because unlike some of the other programs that we've talked about where there are heavy Medicaid programs and heavy insurer programs, there's almost nothing going on in New Mexico. I think it's got one of the highest percentages of uninsured populations in the country. There are wnole areas where there simply are no facilities at all, so we're not talking about whether sophisticated medicine can be brought, but we're talking about who's going to pay for the pickup truck . that they throw the body in out there. | Sandobel County, for example, has an area that is larger than Connecticut that has something like 60,000 people or less, and there are no emergency medical services and no installation, so that this is quite a different ballgame in terms of deciding whether you're going to use this sophisticated method or that sophisticated method. It's a question of whether there's going to he any method going on which is a much more basic kind of decision. So we found I think some defects in the program as it has been operating. One of the paradoxes was the coordinator was a paradox in that he had not moved along with some of the missions that have been expressed by the Regional Medical Prograr sort of personal rapport with a lot of the people involved ra ce ~ Federal Reporters, 10 aI 12 13 14 15 16 17 18 19 20 21 22 23 24) Inc. 25 ‘happened, and started a search committee and they've already 44 don't have ve much vractical importance when it comes down to x p 131 around the state. So this put us in sort of an awkward position} It turned out, however, during the site visit, the dean, who had kept hands off the program for a couple of years, realized that he would have to give it some support and get to work on. the likelihood of Dr. Fitz' resignation which has subsequently - secured a Dr. Gay who is a neurosurgeon who no longer practices and is willing to go full time with this program, and at least all the reports I've been able to get on him are very, very favorable. I believe that he worked with Dr. Millikan at one time in his career so he should have learned something. The other part of the program that we criticized has to do with the fact that they had a number of good projects but they didn't have them molded into very good programs, an excellent example of which was the fact that they had a pretty good cancer registry going which was covering something like 90 percent of the region beds, and the most talented scientist we met in the ones we came up close with was a hematologist who was getting very substantial NIH funding and going into a big lymphoma project and wasn't using the cancer registry. So you could only come to one of two conclusions, either he was not relating his project to the program or else the cancer registries a point of that sort. I don't know which conclusion I'd be willing to come to, but I think that it certainly would have bee} 4 10 1 © 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace Federal Reporters, Inc. 25 132 expected that he would have worke d better with this inasmuch as he did have here in project 17 a proposal for a leukemia lymphoma treatment program. We could go on like that. There were some very, very strong points in the program, one of which -- the best of which perhaps was the emergency nedical care system which was very unique and being worked out by Dr. Hendrickson who was a very dynamic person and saw these problems. It's hard for an Easterner to appreciate these problems. For example, they can't. even use radio controlled ambulances up in the Four Corner area without having -- the distances are so great and the mountains are -- the terrain is so rough, that they actually have to have relay stations to amplify the message just to get a plain old radio telephone call through from an ambulance to ~ a nearby hospital. So they have all kinds of special technical problems and he seems to be very aware of this and I think the only question of the future -~ there's no question about the > quality of that program and the imagination of that program. The only question about the future was whether he would be able to lean on the emergency medical care legislation, and some of the grants that are being made now by the Department of ransportation and Defense to implement emergency medical care facilities -- whether he would be able to get any help from this, and I would think that we ought to continue to look at this to.see whether we might be putting more money into the 10 1 @ 12 13 14 15: 16: 7 +8 19. 20 e 24, 22 23 24 Ace ~ Federal: Reporters, Inc. 25 133 programming of his activities for the sake of enabling him'to - get the help elsewhere, aS a means to an end rather than as. to the end in itself of funding the program. With all of this, I would feel that the site visit report here is very accurate and quite up to date. The kidney program was very disappointing to us and, 7 I have dug into it, it seems to me that what happened is that they have two different groups of nephrologists with some polarization and Dr. Fitz really didn't want to take the effort in his waning days to get them together, so there really wasn't a coordin eed kidney proposal. Subsequently to our site visit, they have come up with a couple of pretty good ideas, and they are in the book here and don't look bad. The result is, however, there's no money in the grant for this and if they are not given develop-. mental component as the review committee recommended, then they would have no way really of moving into this area and I think we would be defeating our constructive purpose because they're well on the way to put together some fairly good proposals. They have some facilities there and I think to encourage them, what I would recommend, is the overall fioure of the review committee but add $30,000 or $40,000 as a specific funding for the kidney programs which have come in subsequent to the site visit which I think would get them started in that particular area ~~ give them the incentive to get them started in that area. 10 1 @ 12 13 14 15 16 17 18 “19 20 22 23 24 Ace + Federal Reporters, inc. 25 134 The recommendations of the review committee and I _ ‘think the conclusions of the site visit were that it would be a ‘good idea to reduce their overall request Significantly for a “one-year period to act as a further’ stimulus as to how serious ‘we are in having them mean business in their reorganization. As I say, all the indices since we were there have ‘been very, very positive and very, very constructive, and I feel that they will be able to come in with a very strong program in about a year. They simoly weran't ready for a site visit and weren't ready for the review as they should have been,]. and this was partly the work of the coordinator. I'm going to move that we accept the recommendations of the review committee for $850,000 funding for one year, but that we add a $30,900 to $40,000 component for the kidney which “ came in after the site visit. MRS. WYCKOFF: Second the motion. DR. CANNON: $30,000 or $40,000? DR. SCHREINER: $40,000. DR. PAHL: The motion has been made and seconded. Dr. Komaroff, you were on the site visit. Would you care to ' ; é ' oped make any further comments? DR. KOMAROFF : No. I haven't seen what's come in on the kidney proposals since then, so I'd have to defer to Dr. Schreiner. DR. PAHL: General discussion, Council or staff? \ce ~ Federal Reporters, 10 iB 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 135 MRS. SILSBEEN: Have we received anything -~ request - for kidney money? I've not seen it in grants review. DR. SCHREINER: -fThey were outlines of a plan but there was no budget enclosed with it. DR. KOMAROFF: The only reservation I have about adding money is that the region has had a fairly significant unexpended balance in the last several years, that there was indication among the projects that they requested continuing support for that they could achieve some savings by just consolidating staffs and coordim ting projects more closely, and they might be able to find that $30,000 or $40,000 out of the $850,000 because they have had unexpended funds in the past.| : DR. PAHL: Mr. Chambliss, do you have a comment? MR. CHAMBLISS: I have a comment. rt's taking a different tack from wnat has already been expressed, but I have the feeling that the site visit team was not totally impressed with the way in which the region of New Mexico is getting at making available to more people basic health services. You note that in the blue sheet that there are approximately 24 percent of the state population, of chicanos and Mexican-Americans and Indians, and the region really has not as yet turned its attention to the health needs of that segment of the population, and the site visit team.did make comments in that regard. During the visit, mention was made that there in New Mexico was a good amount of health restlessness, and we pointed 10 Ve e . 2 13 14 5 16 17 18 19 20 @ 2) 22 23 24 Ace ~Federalt Reporters, Inc. 251 136 that out to the dean and he responded by saying, "We don't have— unrest here. We're not a big city of the East. We don't have the comolex problems that they have in other areas of the country," and I might add, before we could hardly leave the city, the unrest had broken out in Albequerque. We were simply trying to say I think that there are different kinds and different dimensions of health problems that the region should begin to look at, and certainly we feel that under the new leadership they will give some attention to these areas. MPS. WYCKOFF: Is there any Migrant Health Act money being spent in Four Corners? | MR. CHAMBLISS: Very little. As a matter of fact, we found a project that was being funded by the Indian Health . Service just before we made the site visit. It was to provide. Indian children with hearing aids. My comment was that, “Is there not a greater need for basic health services which would include hearing aids to those who need them?" But there are programs going in but there's no comprehensive planning in totality to meet the kinds of migrant health needs that you ‘would consider. DR. SCHREINER: I would certainly concur in Mr. Chambliss’ remarks and I think this was really what was behind our recommending and what was behind the review committee recommending a one-year grant versus a three-year grant. In 10 11 oe #» 13 14 SB 16 17 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, ine. 25 3/) by a quarter of a million dollars is a modest slap on the ‘other words, this clearly puts them on notice that there is to _ ‘groups that he's got to pull together and he's only got a year 137 pe some program coordination, and the fact that we lowered it wrist of our evaluation of what has been going on. But I think for a new coordinator faced with two to do it, $30,000 or $40,009 planning money would be a little bait I think for this incentive. MR. ROBERTSON: I believe the record will show now that it's true that in the past they've had a sizeable carryover of funds. I think it will also show that this current year that the figure would be one that we could all live with. It's certainly less than $30,000, and they have places where they could use that $30,000 if rebudgeting is completed within this current year. So it's entirely possible there will be no carryover of funds left at all at the end of this year. ' They have recently run their figures on it and the only reason they have money left over is that they over-reacted a little bit to the budget cut. With the new coordinator, Dr. Jim Gay, his attitude is one of expanding the program to the peripheral areas, and there's no question in my mind about it. | MRS. WYCKOFF: Have they made any application to the National Health Service for personnel? Have they done anything | about that? “sl 13 14 S 15 16 17 18 19 20° @ 2) oF. 23 24 Ace -- Federal Reporters, inc. 25 138 DR. KOMAROFF: No, and they had an ideal opportunity — in which to do it. They're thinking about in Rio County a ‘rural health center which-tvould use paramedical personnel and could very well have used these two-year men. MRS. SALAZAR: We have just a feedback letter stating that the New Mexico RMP has not made any inquiry about the ‘Health Services Act but the "B" agency has. MRS. WYCKOFF: They ought to get in line right away. DR. PAHL: The motion is for the acceptance of the review committee's recommendations plus an additional $40,000 with the recommendation that this be for the support of the newly proposed kidney activities. Is-there any further dis- cussion? MR, MILLIKEN: I wonder if that extra $40,000 should be in the form of a site visit or a consultant to go and work with them. | DR, MARGULIES: I think you might want to consider whether any additional funds should be left unimpeded so that the new coordinator and the new group could have an opportunity to move in the other directions or in the kidney direction, whichever they prefer, because they have a lot to do there and obviously with the issues -- particularly which Bob Chambliss raised -- they may really prefer to move in that direction. ” DR. CANNON: In other words, don't earmark the $40,000 Just give them an extra $40,000. AL 10 ie 13 14 15 18 20 @ 21 22 soa 23 . 24 Ace — Federal Reporters, Inc. 25 16 139 DR. SCHREINER: It's meant to be a developmental fund to make it possible. | DR. CANNON: I'& go along with an amendment to the ‘motion if you'll accept it, and call for the question. DR. SCHREINER: All right. DR. PAHD: All in favor of the amended motion please say "aye." ("Ayes") DR. PAHL: Ovposed? (No Response) DR. PAHL: The motion.is carried. We will now turn to the ‘fri-State application, with Dr. Roth as principal reviewer and Dr. Cannon as backup reviewer. DR. ROTH: Well, I believe that the Tri-State supple- mentary grant application is relatively simple. This has been reviewed by the ad hoc committee. It has developed cooperative arrangements with Vermont and Northern New England, with Connecticut, and it's main unhappiness is it comes out with ; a name like NERCRO, which sounds like something indecent in Iclandic. ! “4 The Council has already approved the Northern New England application, therefore, as you will notice, that the recommendation on page 4,the blue sheet, of the site visit, is 2 that, although there were some extravagances in some aspect of 18 19 20 ho- NO” NO a ww tom 24 Ace —Federal Reporters, Inc. 25 140 the proposed budget, that they considered that the revised _ budget proposals should be approved; that if Vermont or Northern New England was approved, {hat there be certain additional deletions in the Tri-State proposal. On the final page 5 they have presented figures which reflect both these considerations, with the deletion for the Vermont positions; and I would therefore recommend approval of funding at the rate proposed on page 5 of the revised application. | DR. PAHL: Thank you. pr. Cannon? DR. CANNON: I second these recommendations. DR. PAHL: It has been moved and seconded to accept the recommendations from the review committee. Is there further discussion by Council or staff? DR. ROTH: I can only say, in addition, that this represents quite an accomplishment over a period of the past year and a half in doing the kind of thing that I think Bill Hunt wants done in the Metropolitan D.C. area. When we site visited up there, there was a tendency of Rhode Island, for example, to go its own way with Brown University insisting on having a transplant-dialysis program totally independent of the very nearby Boston thing. So that I assume that this represents a meeting of the minds and some compromise on these issues. Perhaps staff can fill that ‘in for me. MR. MC KENNA: Well, I think you're right. There has i 10 i e@ » 13 14 15 16 17 18 19 20 © 21 22 23 24 Ace — Federal Reporters, Inc. 25 141 realizaation of the need for this. DR. PAHL: Is there further discussion? (No Response) ~ DR. PAHL: If not, all in favor of the motion please say "Aye." my ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. We turn to the final action before us with Dr. Cannon as vrincipal reviewer, vr. Hunt as backup reviewer, this. application from the National Kidney Foundation. DR. CANNON: I'd like to ask we fore George leaves if he would briefly give the Council some information, speci fi- cally how does the National Kidney Foundation differ from other foundations, the National Foundation for uultiple Sclerosis -- and there are hundreds of them. Is there some difference that we should perceive? DR. SCHREINER: One major difference is that it's regionally organized rather than-by states, so it differs from Cancer and Heart in that respect. So it does get into some of the same distribution and personnel problems that the RMP does. Some of the discussions we have about the coordinators reminds me of the affiliates' relations committee pecause we can pick out Ohio and Susquehanna Valley and the same trouble 10 1] eo » 13 14 15 16 17 18 19 20 . * 22 23 24 Ace=Federal Reporters, tnc. 25 142 there has troubled the Regional Medical Program. _ DR. CANNON: It is a professionally controlled group or lay controlled? ~ DR. SCHREINER: Well, it's jointly. I would say it's closer to the -- the organization is a little bit different than the Heart Association. There is a Scientific Advisory Board which is completely scientific and academic and non- geographical. There is a Medical Advisory Board which is representative, with one elected by the Medical Advisory Boards in each region -- in eacn affiliate. There are about 41 affiliates. And the Board of Trustees is a mixture of doctors and lay people. The power -- the corporate responsibility is in the Board of ‘Trustees. DR. CANNON: We have a request for a million dollars| to spent over a three-year period of time. The request comes from the Jational Kidney Foundation. The objective is to have a national program to increase the number of cadaver kidneys for transplantation by seeking the active support of 50 million Americans and the medical community. It has two projections. One is a national project, an expansion of the existing educational program within the National Kidney Foundation. ‘The second is local projects at the state or major metropolitan areas designed for more controlld and intensive effort than is proposed at the national level. In essence, they would like to have this million dollars to spengq 10 VW @ 12 13 14 20 © | 21. 22 23) 24 Ace — Federal Reporters, Inc. 25 in a three-year period of time neefing up an educational program to enhance the donor organ -- voluntary organ donor yrogram for kidneys and ta.educate the people. This would be under the executive director who would, in turn, hire a full-time project director and other personnel. to carry out the message. There's also a request for some equipment, like desks, chairs, filing cabinets, typewriters, etc. | It's my feeling that while this is a very worthwnile and needed projection, that the enhancement of cadaver kidneys must be forthcoming if you're going to get a program of trans- plantation around the country to be effective, I do not see how we can at the present put money into a foundation for this purpose, because there are so many foundations and so many nurnoses that it would continue on infinitun. So I would recommend the disapproval of funding.There's two alternatives to frank disapproval. One is that, if you really want to do this, there was earmarked $15 million for kidney in the last legislative act. rs that true? What happened to that? DR. MARGULIES: No. What it finally ended up being was no more than $15 million will be spent for kidney. There ’ was no e@armarking. DR. CANNON: There.wasn't any earmarked funds? Well, if there are no earmarked funds, then I don't think we can get 10° it @ . 2 13 14 15 16 17 18 19 20 @ 21 23) 24) Ace —Federal Reporters, Inc. 25 22 144 around the requests from other foundations. I thought that was_ a possibility. The other possihility would be using Regional Medical Programs in an educational way, the existing Regional Medical: Programs. I have a lot of sympathy for the program but I just don't see how we could open the gate. DR. ROTH: I'll second Dr. Cannon's motion to disanprove for a somewhat different reason. It seems to Ine that this Council should take a rather pragmatic attitude, that before we start concerning ourselves with building demand for transplantation and dialysis and compliance on the part of those who would provide kidneys, we should have somewhat more assurance that we've got that in-between step of the facilities | and the neople that can make use of it and provide the service. I think therefore, this is premature. DR. PAHL: The motion has been made and seconded to concur with the recommendation for disapproval of this appli- cation. Is there further discussion by Council? (No Resvonse) DR. PAHL: All in favor of the motion please say uaye.' ("Ayes") ‘ ; DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. 10 1 @ . 12 13 eo ! 13] 16 17 18 19 20 @ 21 | 22 23 24 Ace —Federal Reporters, Inc. 25 145 Before we depart, I'd like to just take a moment and ~ thank Dr. Kleiger and Mrs. Hicks who handled the logistics of the meeting. I'd like to-commend our own staff for their effective participation, and I'd like to thank the Council members, both those who vere here earlier this morning and those remaining, for fitting this into a very busy summer | schedule. I don't know whether there's any more business that the Council may have with us. I believe, Harold, we have no further business to bring before the Council. ‘DR. MARGULIES: I can assure you it will be coller in November and next August it will be just as hot. Thank you again very much, DR. PAHL: ‘YThank you all. The meeting is adjourned. (Whereupon, at 1:20 p.m., the meeting was adjourned.)