FP. Pas, wr N J ye wy Ju fhm sy eA RR LAW A Qe pe CJ wales Transcript of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE REGIOWAL MEDICAL PROGRAM SERVICE COUNCIL MEETING Rockville, Maryland Wednesday, 10 November 1971 ACE - FEDERAL REPORTERS, INC. Offictal Reporters 415 Second Street, N.E. Washington, D. C. 20002 Telephone: (Code 202) 547-6222 NATION-WIDE COVERAGE cR-4158 GIBSON ng 10. a : 12. 14 15°] | 23] BB : pa |. Iie 1 | oy - wo vs DEPARTMENT OF HEALTH, EDUCATION, AND WELPARE REGIONAL MEDICAL PROGRAM SERVICE COUNCIL MEETING Conference Room GH... Parklawn Building, ~~ 5600 Fishers Lane Rockville, Maryiend | Wednesday, November 10; ‘ton Pree Feder Reporters Gre. 10 ou 12 1B — 15. “16 an 18 46 20 | my Be -B5 : Rochester N CON TEN TS APPLICATIONS: 7 Indiana | Virginia S I Iowa UV L New York Metropolitan ~ ce Tennessee/Mid-South »~ Washington/Alaska wv West Virginia ~~ a -Missouri - Special Action ve OTHER: Cancer Center in Region X KIDNEY PROPOSALS:. Colorado/Wyoming ~~ | . ne Ohio Valley _~ Towa SY California / : Georgia \/ fe yo Sa ae iB 4 18 30 38 41 63 sa 3B BO: sa Pee Federal Reporters, Ine. 20 10. on “le 13 © 14- 15. 16 Vv ~ 18. of. the Review Committee and the Site Visit Committee, which 19 | 21 22 a 23. 25 j and I would suggest that we start this morning with the Indianp i 24. PROCEEDINGS DR. PAHLs May we come to order for the morning's meeting. | We have a reasonable amount of business on the applications, but if we proceed in good order I suspect we can finish before we get too far into the early afternoon, triennial application with Dr. “Brennan as the principal ge OR aye oy sitiabidics, CESAR pata TP isa UN . reviewer and: ‘Dr. Musser & as the backup reviewer, and Mr. Torbert as our. stage resource individual; and following that application we will then proceed with the ‘Virginia application and I would appreciate knowing if there are early departures contemplated by other council members so that we'll be able — to rearrange matters, but please don't all depart. Dr. Brennan, would you like to proceed with the Indiana findings? (DR. BRENNAN: r wilt, move that the recommendations are identical, be accepted by the’ Council. DR. PAHL: Dr. Musser is not here at the moment. Is there a second to the motion? MRS. WYCKOFF Second. _Coereerettanenarie. “DR. -PAHL: the motion has been made and seconded to accept | the Committee's recommendation on the Indiana application on the triennial application. Is there discussion | “ere 9G RE PON BR 9g os aire ee OR i ae EUR TT A ERT RISER PM ae tg peer TAS, | Pea.Federal Reporters, Bra - — a od | 11 12 oe 14 asd 16 an, | 20 a RB eS Ba | 85. le i by the Council? | Staff? If not, all in favor of the motion ‘please say “Aye.” “ayes” DR. PAHL: Opposed? (No Response) DR. PAHL? | ‘The motion is carried. were ange ‘Dr. ‘Merrill, since “you and Dr. . Schreiner haver both had the opportunity now to review all of the” ‘kidney . eo § aspects and since this motion did include a. itdney” recommen ~ dation, it is my understanding that the notion ineludes , with your concurrerice, the kidney proposal; is ‘that correct?. DR. MERRILL: Yes. _ ros DR. PAHL: Okay. , eo Dept'ectake the Virginia ‘application, whigh is an anniversary application, with pr. Everist as principal reviewer and Mr. Hines as backup reviewer and Mr. Hinkle from our staff. DR. ‘wrentore This is an annivereary continuation 5 | grant application. for. ‘fhe 03 operational year ‘that was site visited by the reviewer and others on Septenber 13 and cr last. This. application has not had a staff anniversary review panel study but has ‘Deen: reviewed by the: Review Committee, and there is general agreenent Detween ‘the site. visit team and the Review Committee’ s report. The region has | had a slow start with the original grantee designated as the . Pea Fedral Restor S, — 10 il cs 13 ea 4: 15 16 ‘17 18 19 20 22 “Ba 25 | then changed to ‘the Medical College of Virginia in Richmons, “now known as the Virginia Commonwealth University, and in | March of 1971 the grantee became the Virginia Regional - team and the Review Conmittee, although the site team aid ‘to await further information from Doctor Perez, the director of the region. Father aiffioult time establishing good rapport with the at. the moment’ the program is categorical; the projects are University of. Virginia School of Medicine in Charlottesville, Medical Program, Inc. whe region has. haa a developmental component disapproved in the February 1971 review cycle; and this marks the. difference between the..recommendations of the site visit withhold total cof tment for the developmental component The Virginia Regional Medical Program has had a medical establishment in Virginia. | They have done this on the basis of categorical emphasis and are now accepted as a viable agency. ‘The redirection of Regional Medical Programs has caused some: difficulty in Virginia, and we were appraised of this, with refreshing candor, by ‘the director. Despite the difficulties, the region has accepted the challenge and . will proceed, albeit cautiously, into this decade. . However , categorical pat. the outlook : is new. The site visit team was impressed with the enthusiasm ‘of the director and staff and came away from the. visit. with the feeling that the “po Bg oe 12 14 15 16 17 18 19 20. el Re. 24 25 I: |} method of handling discretionary funds is rather disheartening | but it is the Review Committee's opinion that the region 10- | of would be used from page 7A through page 78 of the application. “review and management system, but it is legal and apparently | recommended $1,050,000, and the Review Committee, $1,010,000, *needs another year of maturity before the status of the. | developmental component is awarded. I could find no major is going to ‘move as rapidly as possible in the face of some rather overwhelming archaic anchors. They have a strange works. The region requested $1,551,251. The site visit j deleting the $80, 000 developmental component but adding $40, 000 to core to. ‘be used as catalytic funds. qhis tangential fault with the description of how the developmental. component However , there could be some question about the maturity of their review process, particularly the inexperienced majority of the RAG, - I, therefore, concur with the Review Committee 's 's ‘reconmendation to award this region $1,010, 000 for ‘the third operational year, from January 1, 1972 through December 31, 1972, and I so move. MR. HINES: I second. I have nothing to add. £ DR, PAHL2: Okay. | The motion has been made and seconded for approval of the Committee! s recomendations. on pagent ee nS the Virginia application. Is there Council discussion? Any comments from staff? Pleo Federal Reporters She 10 1 “212 13 14 15— 16 18 19 20 21 2a — BH 24 £5 | Virginia area, to see the change that has taken place there. oon oe , | H rowa with Dr. MePhedran as the principal reviewer, Mr._ DR, EVERIST: There is a kidney project. DR. DE BAKEY: I'd simply like to say that it is heartening, since I was on the first site visit to the It's quite a radical change since I was on the first site visit there, and even the changes that have taken place I think they are moving into this thing. ‘DR. PAHL: If there's no further discussion, all in favor of the motion, please say "Aye." (“ayes”) DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. May we now turn to the triennial application from <. renee ee, ; ‘ Milliken as backup reviewer, Mr. Zizlavsky from our staff. DR. MC PHEDRAN: We have a peculiar dilemma in ‘considering this triennial application because the excellent program coordinator and staff felt that they would be embarrassed, even hampered, in pursuit of their excellent program goals, priorities and objectives if they were to receive the full amount request; that is, “requested” in quotes; of $1.147 million because that includes a request for funds to make projects operational which had been previously a approved but unfunded and which they now feel are peripheral Peo Federal Reporters Ge. 10. a 12 13 a 15 “16 “lt 18 197 20 21 22. 23 24 25. first of the blue, sheets, summarizes the financial dimensions |. Teauest be met and the sum for that would be ‘$800, 000 more or figure of $100, 000 that I'm afraid I don't know exactly how category, they have apparently engaged the active interest and participation of the state medical society, of the osteopathic to their new main objectives. I think that the first sheet in the Review Committee's deliberations which you have in the folder, the of this dilemma, and the Review Committee solved their problem by recommending that the coordinator and his State's less. Tt, is kind of a rough estimate but it includes funding} that's based on funding of $625, 000 for the present year -- that- is level funding between the present year and the upcoming one -- plus development component plus a certain that was arrived at, but it is substantially lower than. this total paper request of $1.147 million. Because this might give an erroneous impression about the program as a whole, I'd like to reiterate that the impression of the site visitors was that this was an excellent . Regional Medical Program. For example, in the performance tedical school and of the state medical school, so that their. cooperative arrangements around the state really appear to be first-rate without any serious exceptions we could find. The process that they use, for example, in | Regional Advisory Groups, was imaginative and thoroughly PreecFederal Reporters, re, 10 » dL. 12 13 14 15 16 17 18 19 20 el Re 25 24 . 25 professional. One of the really entertaining things that they had done was. to provide a debate forum for some of the important igsues of ‘the day in the Regional Advisory Group, and this appears to have been very successful in encouraging | participation by members of the Regional Advisory Group... It's difficult to find a serious exception to this praise, this “er in appraise, except ‘that. the. evaluation part of it seemed to “be weak, “but that's something that they shared with many other, ‘regional medical programs . | zon the whole, © think that Dr. “Weinberg and. his staff may: Be ‘more nearly correct; that is, that the previously unfunded but approved projects may be more of a millstone around their necks than a help. they are mostly categorical projects. I understand that there has been a great deal of pressure brought to bear on the Regional Advisory Group and on the core staff to see to it that at least one of these projects was funded. Dr. Weinberg thought that he could manage this ~- could handle this, so that I. guess I'm inclined to support the Review Committee's final reconmendation of $800,000 for the first year triennium and then the other figures as noted on the blue sheet. So I move that we accept the Review Committee! s — recommendation. I would like to hear comments, though, from pthers, from Dr. Margulies and others, who may have views iabout this. Pleo Federal Reporters Pro, | | 10: 11 1p “4g. 14 15 16 17 18 20 21 ee 25 24 29 || Mr. Milliken, would you care to make any comments? ‘| interests in development of their programs and is really far || down the road and not just on paper. This would he my only comment. been placed on them, particularly on one project, has been 19: 10 MR. MILLIKEN: I second. the motion. DR. PAHL: The motion .has been made and seconded. MR. MILLIKEN: Really, I agree with the doctor. The only thing that I would say is that I think this is an unusual cooperative relationship between VRMP and other state DR. MARGULIES : the only comment I'd like to make is directed to the rather unusual circumstances here. Ideally, one would like to think that the Regional Advisory Group would be in a position to discontinue its approval of what it approved in an earlier era. In fact, the pressure which has from one congressman who represents a district in the state and who has enlisted the support of the speaker of the House of Representatives of the state and who sent his personal representative and the speaker of the House to enter the Regional Advisory Group meeting and tell them that this activity simply had to be funded; and it does place all of them in a terribly difficult position. I'm not sure, however, that judging by the frequent telephone calls we get from the same source, that a reduction of the funding is going to resolve their problem. Prce-Federal Reforters, Gro. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 ga 25 11 I would like to think so, but the fact remains that those who lare paying attention to the funding will know that there is money there, that the project has been approved, that there's no reason why these funds can't be used for what they insist they ought to be used for. We may be buying some time with this kind of arrangement. There might be other ways of buttressing the coordinator and the staff and the slightly less secure || Regional advisory Group by any action that the Council might want to take; but they are in a very tight spot and it isn't evidenced in my judgment, either, that there is weakness in this program, but rather that the pressure which is being placed upon them is unrelenting. DR. BRENNAN : ‘Weill, what's wrong with it? Let's get it out on the table. What's wrong with the things that they wanted. to do? | DR. MARGULIES: Well, the one that has been most strongly pushed is one of those kinds of projects which in the project review mechanism occasionally went the route that was not expected. It was a simple, familiar mechanism. The Regional Advisory Group at that time, which had a little less vigor, decided that the one project in particular from Red Oak was professionally unsatisfactory and thought that that would ‘become obvious through the review process as it went national. Now, unfortunately, the Review Committee and the Council were Prea- 44 15 16 17 18 19 20 21 22 BS. 24 25 15 by the staff anniversary review panel for the third year is the same amount that had been received by the New York | Metropolitan Regional Medical Program for their second year. It includes ten percent developmental component and I was on the site visit: team that went there in December 1970 that approved developmental funding for this region. This amount of $2.235 million is within the limit — pene a _— enero that Council had previously recommended, What specifically requires Council action now _ casa EEE really is a request for new funds, a separate request; that is, in Project 29, a Long Island Jewish Medical Center Queens. Hospital Center affiliated request; and this is to revamp a | big city out-patient department. The request is really a very good one I think. It's well written. It goes over problems of big city out-patient departments that are familiar to many people here and proposes solutions for them that seem to be sensible and intelligent. This is essentially a project review, as it has to be. It was felt by the staff nanivertacy review panel that because of health testing equipment and health testing that was proposed in this Project 29 that it fell outside of our Council limitation on multiphasic health testing, but on further discussion it appears that's not the case; that whatever equipment is to be purchased is really part of changing the whole out-patient setup in this hospital and it really is not : Pree Fedoral Reporters, Gre - - 10 11 l2 13 14 15 ie 17 18 19 20. 21 22 25 24 16 an automated health testing system in the sense that we have discussed it a time or two ago. A series of meetings have taken place between RMPS staff and the New York Metropolitan staff and they have come up with the recommendation that's ‘ on this little yellow pir BNE wipe SRS rereenme operon ere STE appendage here, which is that Project 29 be approved in principle, as Dr. Brightman from New York had recommended, d-and that a sum of money, $100, 000, from RMPS would be requested as new money. This is in addition to the previously MARR RMR Hoa Me en inte CEES esata suggested $2,235 million; that this $100, 000 be ‘approved; and that other funds could be got from other sources. — This was actually the original intention of the new York Metropoli- tan Regional Medical Program and they feel that they can make this project go if they have this assistance from RMps. 50, to reiterate, the request. is | for $2235 million toes gsunsty {for the third year; for ($100, 000 in addition to that for the r bigs SEER PBR E AREY LAL AT ENN eee AN i Queens’ project. These discussions enabled staff here and staff at the New York Metropolitan Regional Medical Program to discuss together a number of things that apparently will be useful in preparing their triennial application which will come to us about a year from now. This is another, I think, very good regional medical program. They have made great strides in reorganizing |their relationships with the several medical schools. They BAce-Foderal Reporters, Gre. 10 11 12 13 14 15 16 17 18 19 20 21 22. 25 24 25 of the figures which you see here and which I just went over. faa - tenia r a LER in Sat pasta ERE pee ARES AEE a a 17 have changed their affiliation of these medical schools materially, especially in the last year, so that now the arrangement is that the medical schools must come to the Metropolitan Regional Medical Program with project proposals with specific objectives in mind, and there is no longer going to re simply the. support of somebody who is nominally RMP at the: several medical schools, and it appears that the Regional Medical Program, office has made this stick so that, for example, in some of their latest deliberations when medical schools aids "t come, in with a project at all or didn't come in with it specified well enough, they didn't get -- the support was not forthcoming. So it ‘appears that this is really a good progam. I think it's worthy of. ‘our support and J move recommendation Sass op ae oa ints: The $2.235 million includes a ten percent developmental component. DR. MILLIKAN: Second the ‘motion. ee — DR. PAHL: ‘The motion has been made and seconded. Is there Council discussion? DR. BRENNAN : I think this is the first time we've heard of a project in a major metropolitan area RMP described as very good organization. That's encouraging. DR. PAHL: Is there further Council discussion on the motion? Comments from staff? If not, all in favor of the - ee motion, please say "Aye." Pree Freal Ropero; aa aad So I 14 15 16 17 18 19 20 el 23 24 25 18 DR. PAHL: Opposed? (No Response) DR, PAHL: The motion is carried. Before we turn to the! Trgunsasea/iacSouth: snniver- sary application, 1 d like to have the record show that Mrs. Mars was absent during the virginia application pro- ceedings and I would also like to indicate for the record that the kidney proposals in today! Ss. motions. are. agsumed to have | received the endorsement of Drs. Merrill and Schreiner unless discussions indicate otherwise. We will be coming, of course, to some specific kidney proposals. I'm referring to the ones which are included in the recommendations we have already made on this morning* s applications. ; ‘ } y If we may now turn to the Tennessee/Mid-South © application, Mrs< Wyckoff as principal reviewer; Mr. Milliken as ‘backup reviews! Mr. Reist from staff. MRS. WYCKOFF: This is a request for $2,530,459 for the fifth operational year. The project exceeds Council's previously approved level of funding at $2.19 million. It requires no action. In this request is included the developmental 22 | component of $190,620 anda renal disease patient care system group of projects totaling $266 ,342. The staff anniversary review panel recommends that /the region: be funded at the present rate of support, namely, Pree Federal Reporters, Gre | LO ll 12 13 14 15. 16 1? 18 19 20 21 22 23 24 25 19 $1,906,203. his does not include funds for the renal project, If Council approves these, then the sum recommended should be added to this level. | The panel does not. recommend approval of the developmental component of $190,620. This recommendation disappointed me very much because at our last site visit we thought that the developmental work being done by core was not only a new dynamic thrust but was within line with the national - goal and was, in many ways, the best part of the program. You may remember that we encouraged Dr. Shapiro to pursue this . developmental work as a core activity. This past year, approximately $105,000 1 has been used for this purpose, for such activities as the community outreach program, the practice assistants model in a rural area and the Meharry and Vanderbilt student coalition activitie in Appalachia. For fis, we recommended. core support only and |. suggested | the region reapply for a developmental component later. The heart of the problem in making the developmental, igrant was in the fact that it is now regarded as a merit award for a genuine creative ability in decision making by the RAG. Regrettably, this degree of maturity and balanced self- lgovernment does not appear to have: been achieved here quite vet. The excellent developmental work done by this. region has been the result of a creative core staff and director with the | Pree Fedrral Reporkers, Gh _ 10 “1i 12 13 14 15 - 16 47 18 19° 21 22 25: 24 25 | RAG in a minor role; one of the principal disadvantages being ‘be updated to be consistent with current legislation and to planning. The region now has a health data joint working 20 20 the RAG's narrow representation heavily weighted with medical school and practicing physicians, mainly from Nashville; and due to the domination of the grantee in selecting appointments to the RAG. The net result has been that a few large projects remain on. Gead center and have not moved forward with national priorities, nor do they conform to objectives and goals focused on health care delivery, local goals and objectives. RMPS staff has made several site visits and has found a need to reexamine the region's goals and update them in the light of new national priorities. RAG “by-laws need to provide better working relationships among the institutions sponsoring RMP. Progress has been made in the decentralization of this program and the establishment of seven area advisory committees which are now using: hard data in their program group with CHP and the state health department. RMP site visitors evidently found that the project monitoring and review was excellent. New activities. proposed for. implementation are within the scope of the goals and objectives established at the beginning of this trienniun. I think I concur with the staff panel's recommendatior Peo Federal Reporters, Fro. | a 10 al 12 13 14 15 16 17 18 19° ed ee 23 BA 25 reeppapatees HOE TH 3, 21 of the RAG of the Tennessee/Mid-South be given the hard choice of funding the excellent developmental proposal within | a limited budget or pursuing the old course. This means approving a grant of only Lied _present current rate of 2 ae mag Ueber arpa MISE TT frraecngae etme Sede enter nt mmr shee ntte $1, 906 12033 not including the renal Program; but : I : hope this Rae HORE my will ‘be ‘the ‘last time we have. to use this method, because somehow, osterisibly, I feel we get better mileage out of Sudicious reward plus guidance than we do from prolonged punishment, The “Ad. Hoc Panel on Renal Disease reported its findings on Project #58 and recommended a considerably reduced amount. Perhaps one of our genuine renal experts would like to report on this and explain the reasons for these recommendations. DR. PAHL: Thank you, Mrs. Wyckoff. DR, SCHREINER: Which one is genuine? DR. PAHL: While we're deciding that issue, perhaps Mr. Milliken would have some comments. MR. MILLIKEN: I agree with Mrs. Wyckoff's report and again I think this has the basis for a strong program development and I am likewise concerned with the approach to. aa aga them in terms of holding them back rather than some. positive support on new activities. DR. PAHL: Thank you. MR. MILLIKEN: I would second the motion. 10 11 “ 12 13 14 15 16. 17 18 19 | 20 21 ee . 93 «pa RB relative to the kidney? question about the fact that you should have home training 22 DR. PAHL: The motion has been made and seconded. May we have a comment from Dr. Schreiner or Dr. Merrill DR. SCHREINER: I ‘think in general the comments ——— : are good. I'm a little disturbed about one which shows the fine hand of a consistent prejudice. There are a couple of individuals on our ad hoc review panel who are just completely blindly rigid about in-center dialysis. I happen to agree with where the emphasis should be, and if you're going to talk about community planning and large extension there's no and you should be shooting for that; but I think it's idiotic to say that you're going to home-dialyze 100 percent of the people, because there are many areas where the homes are unsuitable and many areas where you can't have a dialysis partner and many areas do require center backup. In the ) general opinion of | the people who have worked in these. areas, -when you go into the poor economic areas, you're probably going to have increasingly a higher percentage of people requiring center dialysis and the reverse in the more affluent areas. | So it seems to me they have chopped out Meharry Center principally on the basis that they' re not moving toward home dialysis. If there's no motion toward home — dialysis I can see this as a criticism, but it seems to me . Bre Federal Reporters, boo. 10, li lé 13 14, 15 16 “17 18 Fag 21 22 23 25 19 | || view of the discussion yesterday is the fact that Component 24 23 | that to wipe them out is hurting the area in which we want to help and reflects a little bit too much rigidity I think in the application of that concept. DR. MERRILL: Well, I'm disturbed by a couple of things. First of all, the initial report of the Ad Hoc Panel on Renal Disease states -- this was on September 28, 1971, whereas the site visit was October 28 -- and they state that | the region -- they have a large budget request for trans- plantation and intercommunication and typing and so on =~ and states -- the Ad Hoc Committee states that the region has lost| a transplant surgeon and the application has not clearly indicated its desire to increase transplantation; the gurgical capability is thin. : ‘Now, the site visit of the kidney disease group does not touch on that that I can see, but they do stress that the planned program for transplantation, organ procure- ment and tissue-typing is reasonable and acceptable and generally recognized; and I find it difficult to reconcile. The other thing which is of some interest to me in 58-B is deferred apparently because there's going to be a conference by RMPS and the Division of Chronic Kidney Disease ‘Study Group on whether renal biopsies are or are not within the purview of sponsorship by the RMP. “1, myself, have a prejudice ~- and this may only | Pex Federal Reporters She 10 sb. 12 13° 14 15 16 17 18 19 20 | 22 25 24 3) 24 be a personal one and I'd like to hear Dr. Schreiner's comment on it -- about the ultimate value of the detection of bacteruria by a screening program and urinalysis. But I think the thing that disturbs me most, while the proposal is good for the transplantation and tissue-typing and computer. coordination and so on, I see no refutation of the ofthe statement that they have lost -- the region has lost its transplant surgeon and the application does not clearly indicate a desire to increase transplantation. Is there anyone on staff who has any more information on that? DR. PAHL: Bill, do you have any information? MR. REIST: I don't know. Mr. Anderson might know. ‘DR. DE BAKEY: Where is the transplant center, Danville? . | DR. MERRILL: Yes. DR. DE BAKEY: I'm amazed because they've got two or three people there that I know do this, so I have serious doubts that this would hurt their ability to do it. MR. ANDERSON: Itwas very difficult to hear you, Dr. Merrill. Would you repeat the question, please? DR. MERRILL: My question was as follows: On the second page of the ad hoc panel survey and summary, the si sea ne enSn noNeg er ARAM! statement is made that the region has lost its transplant surgeon and application does not clearly indicate a desire to increase transplantation; the surgical capability is thin. I fy Pheo-Fderal Reporters, Gre. 10: 11 12 13 14 15 16 17 18. 19 20, eh. 22 25 24 “BO 25 see no mention of the fact that this has been taken into consideration by the site visit people. Maybe Dr. DeBakey can enlighten me. Is Bill Scott interested in transplantation DR. DE BAKEY: Very much so, and I know of at least three of the surgeons on his staff who are interested in 4 and are doing it. That's why I find it difficult to understand. | | DR. MERRILL: I think that would answer that question." | 7 MR. ANDERSON : “Well, we met with Dr. Scott -- or the site visit team did -- and Dr. Scott assured us that he was definitely interested in transplantation and is now actively recruiting for a full-time transplantation surgeon. “| MRS. WYCKOFF: You know, I hate to raise this | issue, but it does seem to me that where you have two medical | centers as near as Memphis and Nashville, why you have to have two underused systems of transplantation when you might have one good one. I just can't understand it. Do we have some way to examine. ‘the strength of these things and where the eriphases are. s regardless of the region? . MARGULTES : We have been making an effort, as: ab. you | remember ‘in the past meetings of council, to try to identify ona “geographic basis the relative need for a transplant centers which is based upon local resources and population requirements and potential need which can be fairly Par Federal Reborters Ge, 10 i 12 13 | 4s ae 17 18 _ 19 20 21 BB 23 24 2B }and they have been very actively in a transplant effort for a complete. comprehensive program. 26 well identified for dialysis and transplants; and whether this has been applied in the review process -- maybe again, Mr. Anderson, you could -respond to that particular question. The issue was whether this represents an excessive development of capacity when there are medical centers in Memphis and in Nashville which would presumably serve the same population.| MR, ANDERSON: Well, geographically, I don't think this would be true, and the transplantation capability in Memphis is extremely limited, whereas Nashville has really established themselves as a transplant center in the Mid-South number of years. This would help them to perpetuate their DR. CANNON: - What was that about the Memphis” capability being limited? He said that the capabilities in Memphis were extremely limited and I just wanted to know if that is a true statement because I -- MR. ANDERSON: Maybe my choice of words is not a very good ‘oie: They haven't been too active in transplant. DR. CANNON: Because they haven't had funds. — MR. ANDERSON: ves, sir. a DR. MERRILL: Does Memphis have a computer to organize their organ procurement and typing? DR. CANNON: Dr. Merrill, I really don't know. “ALL I know is that Dr. Britt and Dr. Hatches has got a program Poo Fadil Reporters Fe. Ww 10 11. “12 13, 14 15 16 oy 18 19 20 21 22. 23 BA. 25 |l4£ they could get together and cooperate. jfrom the surgical standpoint becomes completely inadequate 27 they've been working on for some time but it's limited in funding. DR. PAHL: Is there further discussion? DR. EVERIST: It would seen to me that this might be a time for us to again bring up the possibility of 910 ia Nr cesses money for the - ‘southeastern area of the country, working together on some of these projects and it would probably save RMPS a considerable amount of money and get a better quality . of care. It seems to be a natural with all the talent, with” McDonald in New Orleans and Hume in Richmond and the people that are scattered around this area, would have a ball I think DR. DE BAKEY: Well, there is an effort ‘being | made. area in an effort ‘to provide coordinated ‘programs, particularly in terms of. utilizing the computer for donors and that sort of thing. There's considerable effort I know in our part of. the country to do this, so I think a little push on the part of helping them do this would be good. “Another comment I would like to make about this, as far as surgical capability for transplant, there's no lack of surgical capability. The problem lies primarily in finding the funds to support a good center organization where you have lall. of the resources available. A kidney transplant program to a0 that in the whole mid-south and. deep: south and southwest¢rn Pree Federal Reporters She 10. 1 12 13 44. 15 - 16 17 18 19 20 21 22 _ 23 24 & 25. -|| personnel for this purpose. It's putting together the total deterrent to providing 1 the best kind of organization, 28 unless it has all the total resources, particularly in terms of kidney dialysis and support of immunologists and others to ereate the total center. AS far as the technical aspects of it from the surgical standpoint, that really constitutes - the easiest component of the whole thing and there! 'g no lack of trained organization and the supporting organization, and this requires funding of the center. Frequently it's not available to the center! s resources and: this is the main I know in our. own ‘setup, where we have been doing kidney transplants for a long time, 10 or. 12 years now, and — continuously doing it, we have to scratch to get the funds to support the total activity. DR. MARGULIES; I think that the idea of the 910 mechanism is most appropriate. The Southeast coordinators have been meeting together to develop a coimiot approach to kidney problems and, as Dr. DeBakey indicated, that is not confined to the southeast area. We will, in the process of developing the new kind eal laa: bic coil P SS BOERS RT tytn of protocol which we described yesterday, Lay ‘emphasis « on ‘the: Ri utilization of the 910 approach because it provides a mechanisi Seieitegeceats cs a for getting around exactly the issue which you, have raised, Mrs. Wyckoff, and I think we should promote the idea now rather Doo Federal . Reporters, Fre. 10 ae 12 13 14 15 16 17 18 19 20 21 22 BS Pa 25 a : | than wait for any further development. DR.. SCHREINER: I wonder if Mr. Anderson could put a dollar value on it.--I can't break it down -- from 58-C, which is the dialysis component, is approved in general at reduced funding; but I can't break down the figures. I think ‘| you ought to-put that back in and recommend to them that they expand for a.four-bed unit and that they come back in with a supplemental application and try to initiate a home-training program as an adjunct to that. : Following your philosophy, I think it's better to xeward them. If they don't have a nurse that two-bed unit may be wiped out. | : pr. PAHL: Mr. Anderson, can you place a dollar figure on that? | MR. ANDERSON: It's in the neighborhood of $10,000. MRS . WYCKOFF: So. $58, 000 would be $68, 000. Do - ARE otis, you need a motion on this to ‘approve the sum of $176, 000 for” ith RRR Faas al ‘ sanebauihaae a ia the renal project? DR. PAHL: Well, the Chair understands that the motion on the Tennessee/Mid-South application is to approve the recommendations. gf the staff anniversary review panel nal aca ERE together with the 3 recommendations ed the technical kidney site Aa BD etree ee Ey 1 RA an SE a en ES OE a eR «Lig cons aa se oa oma atesnae wee visit team, to which is added S10, 900 for section 58-C of the PRRs eA kidney proposal. DR. SCHREINER: For Meharry. hare . Aro-Federal Reporters, Ge u 10 11 12 13 14 15 16 17. 18 19 20° 21. 22 25° 24 25° ‘but somewhat less than the Council approved level, $1.68 milli¢ 30 MRS. WYCKOFF: For Meharry. — DR. PAHL: For Meharry. If that is the motion which has already been seconded, may I ask if there is further Council discussion? MR. HINES: Question. DR. PAHL: All in favor of the motion, please say "Aye." | | | DR. PAHL: | Opposed? (No Response) DR. PAHL: The. ee is carried, i i iA OE TE Hee panes f # We now turn to the Washington/Alaska anniversary application. Dr. Komaroff is _the principal | reviewer and AAR is SLOPES eae ome etiaineeg ON Mrs. Mars is backup reviewer and Mr. Moore from our staff. Dr. Watkins, I apolagize for not noting your absence from the room during the New York Metropolitan review procedure. | | DR. KOMAROFF: This region is currently funded ata level of $1.45 million. The Council has already approved the level for next year of $1.96 million. ‘The commitment that the region understands it has from the director for next year is $1.51 million, and it is requesting somewhat more than that The main reason that the region is requesting additional funds and the reason that the staff anniversary review panel has agreed with that request is that they have Dn. Prev Fedral Reporters, She. 10 ll l2 13 14 15 16 | 17 18. 19 20 el 22 25 24 25 31 | five new activities and they wish to expand their development a component. | | Since the Council last looked at this region there's been several changes that are encouraging. The organizational structure has changed so that five associate coordinators for each of their five key program areas have been designated and. there are five corresponding advisory councils that work closely with the core staff in these: ‘areas.|. ae Their general goal statement has been decategorized. they have moved further away from a primary emphasis on. | continuing education and into newer areas, some of which we' ve already heard about yesterday and I'll briefly allude to. | “Bhetorically, they are pointing more towards the delivery of care to the poor, development of new types of | paramedical personnel, screening and prevention activities, public health education activities, increasing the rural/urban linkages which have already characterized the region, the stimulation of mos, the atinulation of area health education centers which they have an ideal opportunity to promote as par of the University of Washington peripheralization medical - school program called WAMI, which has a kind of zing to that achronym that's uncharacteristic of most of the achronyms we deal with. : They're also encouraging medical audit programs in several private practice settings. They have the satellite pa Pree negotiating - Nisibis caste OAR canteee instruments. “There are a variety of ways in which we could pursue the contract issue with RMPS funds, with other kinds be difficult to locate the funds to continue it. MRS. WYCKOFF: Do you need a resolution for a contract if we decide that it's necessary? @ PreocFedeval Reporters, Gro. 10 li 12 13 14 15 16 17 “18° ae" 20 21 22, 23 24 BS . ROR T EE cin, gia ASAE iat rearpaine oie, ng nest Bog Ra im em acest Sr SP PRES 64 DR. MARGULIES: No. DR. BRENNAN: I'd ask whether you wanted to enter- tain such a motion. There is no formal motion on the floor. MR. MILLIKEN: Don't we have a motion to study this thing? DR. PAHL: ves. All in: favor of the motion to arenes conduct” a study and report the progress of the . design of the east IERIE AI sense TEE study | to ‘the couneiT ‘at “the ‘next meeting, please say "Aye." Fe re Se er Sie Sr IE al a son cn ie RR Geen senaseer icant PSS gees PRE EMEA ant aerate SIRENS CN (aye ny. DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. . May we adjourn and get our coffee and doughnuts, and then following coffee, we will primarily be concerned " HY with the kidney ‘proposals and some items of business from jdetantay, (Recess) DR. PAHL: May we reconvene, please. DR. MARGULIES: We have some other issues which we must address at the present time. t'd like to have just a quick report 1 back to you on one of the questions that was raised before the coffee break. During the '67-70 period of» RMP, if you combined automated technology and other major equipment purahases , the total comes to over $18.4 million. This seems to be large enough to justify some understanding PreoFederal Reporlers Gre. 10 11 12 13 14 15 16 17 18 19 - 20 21 22 23 24 25 65 of what we got out of it. Ohio underwent some discussion yesterday and ‘we agreed that since they have made the proposed changes that I reported to you that we would ask two members of the Council and, if we can, one member of the Review Committee who pre-. viously visited the region, to go out there. I have. asked Bruce Everist and Clark Millikan, who have done something similar for us, to again perform that kind of a duty in Ohio and they agreed. One of the people who was on the previous site visit from the Review Committee was George Miller, and — if we can get him to join the team we can’ get some informatioy reported back to you. | Now, we also have distributed for you to consider with the understanding that it was well-written, I altered” it slightly and it was less well-written as a consequence, a resolution -- or not really so much | a resolution as a proposed _ Council action regarding the creation of a cancer ‘center in the northwest part of the United States. I think maybe we ace EE SEE ene eaten MOREA AIO IEE: should read it aloud for the record, which I'1l be glad to do, “The National Advisory Council. on Regional Medical Programs approves: the granting of $5 million for the con=" struction of a cancer center located in a major medical center in the area served by HEW Region X. ellie eal "The Center, while it is to be an independent, nonprofit corporation, should have, to ensure its perpetuity PleoFederal Reporters, Sue. 10 il 12 135 14 15 16 17 18.. 19 20 21 ee 20. on 25 66 and achieve its ultimate objectives, organizational relation- ships with a University Health Science Center and other ‘medical educational; training and research facilities in Public Health Service Region X. “tn addition, liaison and coordination with the Regional Medical Programs in its area and with the CHP (a) agencies in the various states in Region X should be fostered. "To fulfill its unique potential for making available to those persons suffering from neoplastic diseases subject to curative intervention through cooperative multi- disciplinary treatment efforts in the area, a mechanism for communication, interaction and cooperation with existing cancer research and cancer related agencies in the region, including the existing medical services and the hospitals and voluntary societies, should be developed, "The Center should be recognized as a regional cooperative cancer center rather than the single most important institution in its field, and every effort should be made to ensure adequate regional representation at the Center. | “The Center's planning and programs should have a goal of making feasible for all persons in need of cancer treatment facilities available at a humanistic level. "Other goals of this facility should be education of all health professionals for, and the coordination, Arco-Federal Reporters, Gre. : 10 il 12 13 14 15 16 17 18 19 20 21 22 - 25 24. 25 67 research and demonstration of, optimal patient care in the field of cancer treatment. This Center would be the appropriate recipient of a grant from the National Advisory Council on Regional Medical Programs insofar as these ebjectives are equally pursued. “This Center would have the function of focusing on the problems of cancer research and cancer treatment all ‘the relevant resources of the advanced technological community of the northwest region of the United States. “~The National Advisory Council recommends that this Center include on its Board a representative group of recognized leaders in the field of cancer in its region, and, further, that it convene to advise a Regional Cancer Council comprised of persons throughout Region X as well as a Scientific Committee to coordinate cancer research, education and service and promote regional cooperative arrangements. “and finally, the National Advisory Council recommends that the efforts sponsored by this Center be afforded the advantage of periodic review and consultation by > an Advisory Committee of nationally and internationally | recognized authorities in this field." | DR. MERRILL: Should we include in this some onan nett, | statement about provision for its continuing operational funding; that it is our understanding that additional arrangements for its continued operational funding? | Pree Federal Reporters, Gre, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 R4 25 68 DR. DE BAKEY: Harold, I presume you have already discussed the basis of this and I'm not familiar with it and I don't want to waste the time of everybody, but the only question I would ask is, is this setting a precedent for the Regional Medical Program? I don't mind setting it. I'm.not questioning whether or not we should. Personally, I think _ it's great. In fact, I'm glad to see us set a precedent. DR. MARGULIES: Right. I see no reason not to rega it as precedent~setting. I think the one thing that has not clearly been in here and which Dr. Merrill appropriately brought up is some statement regarding the necessity for an. effective source of funding and technical assistance to-main- tain the professional activities within this Center after it has been constructed of the kind, of course, that the National Cancer Institute could provide; and we could add that kind of wording. DR. DE BAKEY: ‘That's good. DR. EVERIST: With that. added, I move we accept ela epee ase ranepnneteR IOS [ree secsonemsnuete this. DR. DE BAKEY: Second. wane DR. MARGULIES: With that addition, the motion is that this be accepted. It's been moved and seconded. Any. further discussion? All in favor, say "Aye." ("Ayes") | DR. MARGULIES: Opposed? Aaa aan soa esorapetang ts eer (No Response) Pree Federal Reporters, Fue 10 11 le. 13 14 15 16 17 18 19 20 21 2b 23 24 25 69 _DR. MARGULIES Thank you. . ered spe DE pene gh eh ROLDAN T ARS EAA TM RTM me wegen aerainttis mene DR. PAHL: We have before us in terms of formal applications the kidney proposals. which were deferred from yesterday's consideration and I would like to now return to those, the first one being that from: Arizona; and if I might just ask Dr. Schreiner and Dr, Merrill to lead the discussion and make appropriate motions on these kidney applications which remain before us. DR. EVERIST: Does that require action? DR. PAHL: ves. nee are parts of the "formal - requests of the regions which were not taken up yesterday in the motions. We have three from yesterday which were not acted upon, and then three supplemental kidney proposals. DR. EVERIST: All right. DR. PAHL: Dr. Schreiner, may I ask you to start a? i if the discussion on the ‘Arizona kidney proposal? DR. SCHREINER: I thought in this instance the general review of the Ad Hoc Panel on Renal Disease was satisfactory. They have had a rapid buildup in good personnel in this area, I suppose the most outstanding person being David Ogden who has moved there from the University of Colorado at Denver. : DR. MERRILL: And Stokowsky. DR. SCHREINER: Yes, Stokowsky also. I think they have got the professienal capability of mounting a good program. Pleo Federal Reporters, Gro, | 10: 11 12 13 14 15 16 17 18 19 20 21 22 25 24 — BS 70 The site visitors recommended approval with some budget modification,: and they particularly threw out the physician education coniponent which apparently would not be one of the strongest aapects of their proposal. I thought’ maybe we ought to have some discussion about the loan program because it seemed to me that this was rather sumnarily dismissed by the Review Committee. What they're proposing is kind of a, as far as I know, innovative -- but I haven't been here too long -- in that they're proposing a revolving loan setup with a bank, properly supervised, in order to initiate transplant, with the idea that the rehabilitated patient then will pay back out of his earnings, if he is rehabilitated. This is kind of a positive feedback system that appeals to me, if workable, and I wonder if other people had some views, whether this would be a workable experimentation. DR. MERRILL: They do state in their discussion of that that there is no guarantee that the total amount of the loan would be repaid, and that would put us in the position of paying, at least in part, directly for patient care; and I think that's almost exactly what would happen; and that may be the reason for the unfavorable look at it. I would agree with George on that. They do have good people. Their ideas are good. I think the Ad Hoc Committee has quite correctly | thrown « out not only the physician rennet AE Rt genia sept tene eeu am enaam Arce Fedoral Reporters, Gre. 10 11 12 13 14 15 16 17 18 19 20 el ek 23 24 £5 71 education, but the so-called detection progran, which is a very difficult one to implement and get any meaningful data from. But the rest of it I think certainly bears support and I would agree with the recommendation of the Ad Hoc es * eR oi subi teongeppig geobhe beet EAPEAB Eins a aa anni PT DR. SCHREINER: Tf move to approve. Committee. Pp DR. PAHL: Is there a motion? DR. PAHL: There is a motion to approve the SAO ES EREE Nae recomaandats one of the site visitors for the Kidney | proposal wae a aE i ean edge ate 1 Eten: hate ee TAR cr sbi neat telah tn the Arizona application. Is there further discussion by Council? If not, all i in favor of the motion, please say "“Aye.' ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The Motion is carried. — Dr. Merrill, would you please lead the discussion ! on the Colorado/Wyoming ‘exiennial application kidney proposal? DR. MERRILL: i must confess | that a r looked at oom men on of ob Peueyes gan that review yesterday I was unimpressed, but the original application I think gives a much fuller description of what they're trying to do. I had initially envisaged simply from the summary that what they were going to do was to set out to dialyze children as an end in itself, which I would heartily disagree with and I think Dr. Schreiner would, too; but they 'r4 not, if one reads the full proposal. Pree Federal Reporters, Gre, 10 11 1é 13 14 , 15 16 17 18 19 20 21 22 2d 24 20 72 They are going to have cooperation with Colorado Transplantation Center and that certainly has a tremendous capability, and although they do not mention the people involved by name, I'm sure that they are going to get involved in that -- I'm sorry, they do here -- so that would complete my approval of it. Now, some question was raised about the fact as to Pes pace eae Te MATEO A seer whether or not there should be separate facilities for children Cokes, . pe RS SSH bos age ber Rge ea: cA APRN RA MEE TTR PI nae vast ote gest pcan MeN and I'm absolutely convinced there should. Our own experience leads us to believe that it's just impossible to take care of six-year-old kids in an adult ward. They do have a good pediatrician in charge. They have all the capabilities for dialysis and transplantation, and I think nS experience in California with pediatric transplan- ote a, Sarit ETS Roe oet ener COV MAND nis ths eA a tation sone under the ‘supervision of pediatricians, has been a good one, as “perhaps ‘opposed to our own; and I would think Le ERT RRR i ITER marge gt BA A NA aa ae tig TA SoA RE RULEUES, ol OMGeSeptagrau os seugs ag this was well worthwhile. AE gayM tn oor DR. PAHL: Thank you. Dr. Schreiner? DR. SCHREINER: When we discussed this, as you remember, we talked about the number of beds and I've since had a chance to discuss this with staff, and apparently this unit is continguous with an acute unit, and while funds are not being sought for the acute unit, the actual arrangement of nurses is going to be such that they will be or can be spread over an adjacent unit, so that helps a little bit. Paco Federal Reporters, Fre. 10 il 12 13 14 15 16 17 18 i9 20 el 22 23 24 25 motion for approval and it has been seconded for acceptance of et 73 DR. PAHL: The Chair understands that there is a eR cami THN ad «TE ar a Ea RARE MOAT SES For tata gE bg the site visit team recommendations. on 1 Project _ 29 of the Dasa EAE reat i dip toa spacscseagh tn ean yp aa cadeial Colorado /vyoming application. Is there further discussion by Council? If not, all in favor of the notion, please say "Aye.' ("Ayes") DR. PAHL: Opposed? {No Response) DR. PAHL: The motion is carried. “ttt TSE E mee gegen eaeomntete ces peeicesatescmnetene sengeetegeeateeM the last one which was deferred from yesterday, Dr. Schreiner, is the onio valley kidney proposal, and I wonder if you would lead the discussion on that. DR. SCHREINER: Well, to be perfectly honest with you, I'm not wild about mobile transport units for organs. They might work in a close geographical area, but it seems to me that the goal of most of what we're doing -- for example, the goal of the southeastern network, and the negotiations that have gone on with other multiregional programs -~ suggests that motion be in the other direction; and that is to enlarge the dialysis applicant pool or candidate pool if we're going to seriously try to apply typing; and if you're goingto do that, the idea of having a truck just doesn't work. You have to be able to fly them around to the various areas and you have to get them there in a reasonable hurry and there's a lot of portable containers that are suitable. for this activity. Prce-Federal Reporters Ge. 10 il 12 13 14 15 16 17 18 19 20 21 25 24 25 74 It's true you can't profuse them, but I guess some of the new smaller incubates -- maybe John has had some experience with-- they're a small fraction of the size of a Belsor and it may be that they would be suitable even for air transportation with profusion going on. But at the present time, it seems to me that you tie up a fairly large piece of expensive equipment that's only working a small part of the time. I think of the difficulties that we've had locally here funding the Heartmobile and how you can drive by that hospital many times and see it parked there in the driveway doing nothing. It does some things, but it's a lot of expensive equipment to have for the short time that it's being used. I'm not too warm about that. DR. PAHL: Are you making a specific motion? DR. SCHREINER: I'd like to hear John first. DR. MERRILL: I think in general I would agree with you. I think the California experience has shown pretty clear] that with simple profusion and cooling alone you can get eight hours survivals and good function, and the Belsor apparatus will take you up to 48 hours or even longer sometimes; and it seems to me that their program should be pretty well established before they can document the need for preservation beyond six or eight hour period. If they can do that, they're really getting into more than a regional; they're getting into almost a -- if you Y Arco Fedoral Reporters ne: 10 Ll 12 13 14 15 17 18 19 20 21 22 25 £4 25 75 need to hold something for 48 hours, you can fly it to Australia if need be. So I agree, that I would rather see documentation of the necessity for this and have them show us the fact that they cannot do it with simply eight hour preser- vation. For instance, we have had kidneys from Rochester and as far as Minneapolis which have not been put on the Belsor type of apparatus. DR. SCHREINER: This year, here in Washington, we've had transplants from Atlanta, Charlottesville, Chapel Hill, Richmond and Baltimore since last January, and we flew most of them in on commercial airlines. The one from Atlanta came in on a commercial airline ina picnic basket. DR. DE BAKEY: I would certainly agree with what has been said. We have done the same thing and, in fact, have been working experimentally with various methods of preservation and have even developed one in our own shop where we can preserve them and get along and function. I say, we have also had the same experience and we've been working with preservatidn chambers of various kinds, some of which have been developed in our own shop; and while they certainly can be effective up to 48 hours easily -- in fact, in one example it was longer -- we have yet to demonstrate the need for them. It's a nice sort of experimental activity and it's good to be able to write a paper about it and talk about it, but -- and we've Pree Federal Reporters, Ge, 10 11 12 13 14 15 16 17 18 19 20 21 22 25 24 25 76 spent quite a little bit of money on it, but we haven't demonstrated the real need for it. | DR. MERRILL: It's a little bit like the pole vault | record. Everybody tries to get an inch or an hour beyond the next fellow. It really doesn't have all that meaning when you get up to 48 hours. DR. PAHL: Is there further discussion? DR. MERRILL: There is one other kidney project in here, and that is the dialysis technologist; and I would gather that that was approved. I would think that the man on the scene would be the important man to know about that. Do they need a dialysis technologist? And that's already been approved by someone on the scene and I would think it's all right. DR. PAHL: May the Chair have a motion for this proposal. DR. SCHREINER: I move for rejection. DR. PAHL: Is there a second? PR.MERRILL: Secones_ MRS. KYTTLE: ‘That then has the effect of amending the dollar amount previously recommended three years downward. DR. SCHREINER: That would go down by the 69? DR. PAHL: The dollar amount recommended yesterday. MRS. KYTTLE: Providing that this was approved today DR. PAHL: All right. There is no misunderstanding PreoFedoral Reporters, Gro. 10 ll 12 13 14 15 16 17 18 19 20 20 24 25 97 that the final recommended level by Council zoe oe appli- erin SRE i phe SIP CATT ENCOEE Rs a ogete mati spars SM acer tl oe cation is such as to sxetude the kidney provosel if this Ro nantes ee RE NET ta Si ts ece AE OORT, ak ces AM iy LI, motion carries. Is there further discussion on the motion? DR. MERRILL: The kidney preservation ‘transportatior system, because there is another one which is dialysis technologist? DR. PAHL: Yes, sir, the one under present dis- cussion. Is there further discussion on this motion? If not, all in favor of the motion, please say "Aye." ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is S Carried: a aaidilladaiaiaia ee eee cen ggmeae renee \\ Dr. McPhedran has asked that we discuss the Iowa di application with respect to the kidney proposal. I was under ory ta mre sensor a “ . a the impression that we had taken action on this yesterday, but if it is the Cowmcil's wish we may reopen this for consideratic Dr. McePhedran, would you care to make a comment? - DR. MC PHEDRAN: No, I'm sorry, I think I should have excepted it from my original recommendation because I think that it, as set up in the previous discussions, looked as if it required special discussion. DR. PAHL: I see. I'm sorry about the misunder- eae NO RREDEH ine ns ete Mata ange nt MTESE SMD IRE RRR Mg standing. I think the record should show, then, that the eran : Sa pang srs eB PEND T someone mm eee ager eg CRE ae TE EN PY aportars, Gre. Pree Federal 10 11 12 13 14 15 16 17 18 19 20 . el “22 25 24 25 wee 78 action taken yesterday by the Coungil. Joes not #nclude the sum aiegegnesene Fae eg " TER armies ae requested for the kidney aspect of that proposal. pr. Schréine aioe ES oro sat i cocoon on this aspect then? DR. SCHREINER: I looked at this one. The only thing that 1 would raise a question about in terms of the review is whether or not -- and I'm not sure mechanically whether they received a previous grant for subregional centers. If they have, and they're in the business of setting up sub- regional centers, then it seems to me that the staff forces who are subregional center management might be a worthwhile investment. I think the short-term teaching programs don't really excite me and apparently didn't excite the Review Committee and didn't excite the site visitors. So I think I would agree with their disapproval but I would ask whether we are funding subregional dialysis center establishment in the state; and if so, then we might revive that aspect, although it was relatively small. DR. PAHL: Can staff provide us some information on the point raised by Dr. Schreiner? MR. ANDERSON: I'm not sure I can comment on the whole thing. I'm not sure I can answer his entire question. I*1l only speak to the issues which I'm familiar with. The renal panel reviewed this application and this or Dr. Merrill, would you be prepared to lead the ‘discussion xr Prce-Fadoral Reporters, Fro. 10 li 12 13 14 15 16 17 18 19 al £2 25 24 25 79 was the second application that had been turned down by the Iowa RMP. The Iowa RMP requested a site visit because it did not feel that we had sufficient information or felt like we needed additional information to make a determination. Dr. Ed Lewis did make a site visit out there and I- think Council members have his recommendation, This is a request for one year and Dr. Lewis recommended that it be supported -~- or that the nurses training portion of this proposal be supported only. DR. PAHL: Thank you. DR. MERRILL: Well, I would certainly agree with that. I think, as has been pointed out, their training program perhaps is not the best written in the world, but I think it's a very important concept and I wonder if a year of experience would not allow them to come back in with a much better proposal. I note that although the Ad Hoc Panel on Renal Disease disapproved it in toto, that the Review Committee isuggested that the nurse training portion of the proposal be funded in part. MR. ANDERSON: The panel said that they would go lalong with the recommendation of the site visitors and the site Yisit was made after the panel had met, and the committee had the site visitors' report. DR. SCHREINER: So that you're proposing $19,000 of it? Pree Federal Reporters, Gc. 10 ql 12 13 14 15 16 a 18 19 20 el 22 25 24 25 80 DR. MERRILL: Yes. pomeneay econ att, cA BEL At OE Ty DR. SCHREINER —— I would agree with that. DR. PAHL: The motion has been made and seconded to approve the $19,575 amount relative to Project 23. Is. there further discussion on this motion? If not, all in favor penetra neat neritic ee penn PRN rng, Sia sees say "Aye." ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. ne DR. MARGULIES: I just wanted to report to you the fact that when I talked to Jim Musser yesterday he pushed very vigorously the idea of tying in more effectively and more formally the facilities in the Veterans Administration hospitals and we have agreed to get together and to begin to work toward those linkages, which have been casual rather than well-planned; and I think the circumstances are good for that purpose. He has freedom to share his facilities now very fully and we'll be coming back to you with a report of progresa on that. compara DR. PAHL: We have three supplemental kidney if oa applications. The first one is from California, with Dr. Merrill as principal reviewer. Mrs. Wyckoff, please, if you will leave. MRS. WYCKOFF: Yes. PrcoFaderal Reporters, Gro, 10 il 12 13 14 15 16 17 18 19 21 22 23 24 25 81 DR. MERRILL: ‘The California proposal is a giant of a proposal. I was reminded in reading it of the story of the little boy who was drawing a picture with his crayons and his older brother looked over his shoulder and said, "What are you doing, Johnny?" And he said, "I'm drawing a picture of Goad." And his brother said, "Why, that's ridiculous. Nobody || knows what God looks like." And Johnny didn't even look up; he said, "They will when I'm through." (Laughter) DR. MERRILL: And this is the kind of thing the California proposal is. Now, let me say, in all seriousness, that California has a tremendous competence. I know most of the people. A number of them have trained with me and they've got a tremendous organization and they're doing extremely well. Perhaps one of the drawbacks of their proposal is that they are already established and doing so well. They have, as you know, some nine areas; and of these nine areas, six of them are already actively engaged in the transplant business and they now propose to link all these together, and they did this as the result of an original application which was originally disapproved because of the absence of an overall California renal program; but they were given $122,000 in seed money with which to start this. They come in now with a large proposal. - In essence, what they propose to do is the kind of Aree Federal Reporters, Ge. 10 11 le 13 14 15 16 17 18 19 20 él £2 25 24 25 82 thing that they have already been doing, but to link it with each other with a ccisputer bank, good tissue-typing facilities , information on what happens to people on dialysis, what happend to people on transplantation; and in addition, they propose one of the most ambitious projects, and that is to have California and California alone organize and set up a supply of antilymphocyte globulin. I presume they will share this, when perfected, with the rest of the world. | The proposal itself is rather vague and it has a mumber of inconsistencies in it. I won't read all of them to you, but I would like just to note a couple of them. They do mot tell us about where funds for donor kidney removal are going to be obtained, although they do mention that it should be utilized. They don't tell about which individuals are: Bpecifically going to be involved. They do include in their pudget in a very large way professional personnel, including transplant gurgeons and trainees in each instance, something that we wondered about. | They state they're going to have a large conference posting $4,000 for planning the development in antilyphocyte globulin and this is. going to be supported by the Upjohn Company, who ‘to date ‘has not been able to provide us with antilymphocyte globulin because they're having trouble. They are going to invite as a consultant Dr. Startsed, who said lonly two weeks ago at the American College of Surgeons that in Aroa-Federal Reporters, Gre. 10 11 12 13 14 15 16 17 18 19 20 al ae 23 24 25 $625, 287. I ._think..California in the present state of ‘the art 83 spite of the fact he was the first to use antilymphocyte globulin, he had really no evidence that it had made an awful lot of difference in his program. So they've got quite an ambitious plan which really extends a program which is ongoing and ongoing quite effective] and they themselves point out that one of the reasons it is is because they have done extremely well with third party funding with Medical. They propose to, in the State of California or the California Region, have a number of these Belsor apparatuses running around between hospital and hospital, and I'm quite convinced, since the data itself came from Los Angeles County some time ago -- that is, the data I quoted you -- that that is not necessary. i think the upshot of it all is _the recommendation by both the ‘Review Committee and the Site Visit Committee that . gst RIES OAL erat sree eco AN 8 PANG MN CREO IOLA LORE ese Ra TI NS eens ts ts ents seb they be funded, but drastically reduced; and the figure that is quoted here in the blue sheet is | $214, 500 out of a requested eM cpa te NERTSE SE att Te Ft nf iEEbE tee hs damp a acs th i eens te asia MRMS i ate gi ns EE OTT can get along perfectly well - on that. pene en a DR. PAHL: ‘Thank you, Dr. Merrill. Dr. Schreiner? DR. SCHREINER: I think that what we're going to have to do shortly, that we haven't mentioned in previous Council meetings, is perhaps take into consideration the level of state aid, This has been a rapidly changing situation. Yi PreaFederal Reporters, Ge, 10 11 12 13 14 15 16 17 18 19 20 el 22 235 24 20 84 Nine states, if I recall the figures correctly, about three years ago had any form of direct dollar aid for renal patients; and it's grown in this period of time to 25, the latest figure that I have. I think that in states where you have a well- developed program of direct aid by the legislature and where you have a very liberal Medicaid program, that a lot of the kinds of things we're trying to provide to other people can really be provided by that mechanism. In a way, I suppose it's penalizing people for being progressive, but on the other hand, if we have the concept of startup funds, then we ought to be concentrating our shots on the have-nots rather than the haves in this particular area. So I think this is an area that's done a lot of fine work and they have so many sources now of financial support that they can probably run this program on a reduced amount. I would agree with this. tn DR. PAHL: All right. It has been moved and seconded that the Committee recommendations be accepted,-which |-- lmeans that this sum of money is included within the existing Itoudget. Is there further discussion on the motion? DR. OCHSNER: May I just make a statement, Herb? I would feel that we, regarding what you said about funding la transplantation surgeon, that we should not do this in a state such as California where they have a plethora of Pleo Faderal Reporters, Gre. 10 ll 12 13 14 15 16 17 18 19 20 al 22 20 24 25 85 vascular surgeons. They can get plenty of people to help. I felt the same way about Vanderbilt. ° They wanted us to underwrite a transplantation surgeon. Now, they've got a fine department of vascular surgery at vanderbilt, but if they can get money from us to get another faculty member they want to do it. | DR. MERRILL: I think they have on their budget something like six transplantation surgeons; that is, their staff member and some six trainees, The Review Committee pointed out that there was a question about the justification of requesting a portion of the salary of every transplantation surgeon in the State of California. By the way, California, which I found out from this, is the first state to have a concrete society of trans- plant surgeons, which is another indication of how medicine is becoming fragmented. DR. PAHL: Is there further discussion? MRS. MARS: I'd just like to ask how much actual duplication is there in the programming here that we're paying for as to what's being done already in the state from other sources? | DR. MERRILD: There are two’ places in the area which are not doing transplantation. One is the Watts area which we discussed at the last meeting, and 1 think this is certainly justifiable to set this up; and the other is Loma Pico Federal Reporters, Gre, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 86 Linda. Whether or not when they get through all of this transplantation will be more than they need to take care of the patients in this area requiring transplantation is anybody's guess, but right now, of course, they're getting a good many patients from out-of-state. I don't think those figures are available. It might be something to look into. DR. PABL: Thank you. Is there further discussion? If not, all in favor of the motion, please say "Aye." ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. SLOP apemateaermenopenniia sit tie CEs 2 f "Georgia ‘application with May we now turn to the Dr. Schreiner and Dr. Merrill as discussants. The record will show Dr. McPhedran is out of the room. DR. SCHREINER: In this instance, there are three basic activities that are proposed for support. One is the existing transplant activity. The second is the subregionali- zation and various aspects related to dialysis: and a third is a development of a computerized clinical diagnosis and management of acid base balance. As you: may or may not know, such a program is available and it's very cheap to rent. All you have to do is pay for the telephone line and the terminal, and this was done up in Boston several years ago, and it's my understanding it's Pree-Federal Reporters, Gre. 10 ul 12 13 14 15 16 17 18 19 20 24 BO 87 available any place that you can get a telephone line. So I think this would be a complete waste and duplication of effort and I would be against it. I don't have in the papers that I was given a complete breakdown of the transplantation program. There was $211,000 requested and the Ad Hoc | Panel recommends $46,000. Sinan AB Lae ea SOc AN oe _ oer ORS cet agp ress PRI been AEE, ene re . ne pilin | Ochsner's ‘remark and delete them. If not, it appears to be a piece sere vee reasonable pruning of the request. The area facilities probably are the most construc- tive portion of this. There are good people in Georgia, although they lost the sparkplug of the Brady dialysis effort that was moved to Virginia. They are replacing him and I don't think that the activity will be quite as high gear over the near term but they're developing replacement personnel which will slow them up a little bit I think. So I think providing funds up to $35,000 for the area facilities is a reasonable request, and they recommended deletion of the nephrology component at the centers as being part of the existing resources and this is also a difficult thing. I would go along with my previous remark; that is, if you really expect a center to provide backup, then they are going to have to increase their staff by a little bit. So I would be in favor of putting back at least perhaps a half a salary for each center that is actually open. Now, if they don't open a AES REE ering, renimis soe . Tt ‘that “includes any funds for surgeons, ZT would second Dr. Pleo Faderal Reborters Gre. 10 11 12 13 14 15 16 17 18 19 20 él 22 23 24 25 88 regional center, then I don't think they need that; but if they actually did open one, I think a half a salary for a faculty person is not unreasonable. ae hinds Hoc Panel ISS AE Rt Seda yh cae se nina ee recommended completely deleting all the in-center ; personnel Seth aaeormaats ser SES Sh Siac Ha, and I think I‘ ria 1 put back two half-salaries pu) oe them | contingent upon actually opening up an area center. wie te ie. a aenragee bre ie cigs hy Ree ELSRS REts vig sae EA RITE Ce REBT MAES 22 A ibpliewn sees sire stnet sie DR. PAHL: Thank you. Dr. Merrill? Shier EE Reape ag DR. MERRILE: I think I agree essentially with ee RTE what Dr. Schreiner said. DR. PAHL: The motion has been made to accept the Binet Seiten panel's recommendations with the additional statements _ Dr. Schreiner added concerning _ the ,yhalf-salary contingent aap RR ate Boe at's a ampere neces, upon the opening and functioning | of the area centers. Is be BSE there further discussion on the motion? DR.SCHREINER: And if the $46,000 does include a cet surgeon's salary, I would delete that. f . / a - ” aaa ~ - — DR. PAHL: Yes. I'm sorry. I forgot that part. Is there further discussion on this motion? If “Tot, all those in favor of the motion, please say “Aye.” ("ayes") | DR. PAHL: . Opposed? (No Response) DR. PAHL: The motion is carried. o The last supplemental kidney proposal is that from i rochester.’ pr. Schreiner, will you please lead the discussion pe PCSRE PCIE vagoperte a SS ARREREMIESEN OY recs tara oy tH. ae oad o> Mo oe Oo (> an GI w re ~ é 18° 19 20 21 22 | 23° 24 85 89 on this. DR, SCHREINER: I think I have here a little dis- ge ao Z SBN, mst ae tH RRS * Ea ee on yp sts OBEY et! eae se emo RPE om any RH ERS agreement with the Review Panel. We have some _Supplemental Beds ht NORMED Haas MAES int paso ARR ee tra als Ne ae oe ote pe nm paints: Reape an a OME A CRN ENE material that's | ‘dated September 1971, and I'm familiar with this are Of course, they have a very well-developed medical team in Rochester in terms of both large surgical commitment b oth’in neurology and vascular surgery. It's one of the best coordinated groups to that extent, and they have a good nephrology program with trainees and so forth. _ At the present time they have 41 patients with terminal renal disease. The estimated area load within the area is about 45 to 50 patients a year. Their total capacity that now exists is for a total of 49 patients and this is restricted principally by two things: the lack of a physical area at the Strong Memorial Hospital for care of transplanta- tion patients; and then, the ability for them to plug in on the Sony-West typing plant. I think it's a well thought out plan. The hospital is willing to contribute the space and it's willing to pay. for ten percent of the remodeling; and whereas it was recommended for disapproval, I think that I would. like to consider it for approval. I think it needs some staff work on pruning the budget a little bit and I can't make a specific recommendation on that without further study, but I think it probably should I be funded at a xeduced level. awe pane ia : Peo Federal Reporters; ne : us bos ea. 10 li 12 135: 14 15 p 16 | al 18 4g 21 BB 25. “project was unrealistic and not in line with current medical is a fine proposal. It's quite realistic and it's completely - around the hospital, and certainly the ‘hospital should bear asking te: tie in. with the Sony-West program but I would assume "from what they say here. ‘that they are, indeed, the center for 90 DR. PAHL: Thank you, Dr. Schreiner. DR, MERRILL: I was amazed in reading this over, ee ARS Renal Disease Ye oat cere aes be tele this Proposal, % to read hanaiae the } Ad Hi Serco SG SEE Te TREE hg Ste recommended 4 eae ces ia virco abate Pea. approval, primarily « on the grounds that. the thinking, because I wholly agree with Dr. Schreiner that this in line with current medical thinking. I have only a couple of reservations. one is, I agree, first, with Dr. Schreiner's comment about funds for remodeling. I think that that should be looked into very carefully. They're simply” going to create a ward apparently for transplant patients So ‘that they won| 't be scattered its share of that. rt am not sure that they need four cardiac monitors for a four-bed transplant unit, and I would recommend dis- approval of that item, if one can disapprove an item. the: only other thing that bothers me a little bit is the fact that this again, like California, is an established program. Tissue-typing they say was undertaken in the fall of 1969 and now they" re asking for support of this, and they are this whole coordinated program. They state, for instance, Pleo Fa ederal Reporters, Shu | 10. ll 12 13 14 15° 16 ay 18 19. 20-1 21 2-29 25 94 25 “Which is reimbursible, perhaps more reimbursible than chronic “@ialysis ona long-term basis, and I would think this would — be a self-sustaining operation. It has been in our hands. in cost in these specific areas. “of Council discussion. Is there further discussion ¢ on, this 91 that this laboratory, meaning the tissue-typing laboratory, serves the renal transplantation program and a newly developed bone marrow transplantation program and the Sony- West organ exchange program. Now, if that is true, how have they supported this before this; and why is it necessary now to come in with support for it or perhaps we should ask the question, how much in the way of supplementary. support do you need for extension of this? Cértainly tissue-typing is one of the techniques I would recommend that the project be funded but oo perhaps if these questions could be looked into with reductio _ DR. SCHREINER: I agree. ecaernepe TEE DR. PAHL: It has been moved and seconded to. ‘ase et iti Sea wate i eet os approve Project 21 but with negotiation by § st Sean SRE fee aig HPT pena saga sat kang ese 3 ACTOS ansiee on “the ‘basis echtevtay angie Sane ape ge allan Mo al aeseeed motion? MRS. MARS: I think that ali this. beings up again the question of duplication of work and use of funds. We seem to be getting in further and further into these kidney projects, spending money, and we. haven’ t got, that. much, money | - to apend to be able to throw it around unwisely and duplicate © Proc Federal Reporters, Gua 10 il 12 13: 14 “16 1 18 19 23 24 25 kind of. a survey has been conducted and we do maintain a _ resources which are available. If there is evidence of ' duplication or if it appears that someone wants to put some- to do again the next time around. 92 work that is being done. It seems to me that more or less what Dr. DeBakey suggested for the machinery part could more or less be done, a review by staff, to see that we do not duplicate kidney programs that have already started, and some sort of a survey could be made. DR. MARGULIES: Perhaps it's because we haven't adequately brought you up to date on this, but, in fact, that review on a geographic basis of all of these projects before they come in; because the Council has expressed this concern regularly, as you have, so when we identify something like the program in Rochester we very clearly identify any other thing right next to what already exists, we do bring that to the attention of ‘council : Perhaps we could be more explicit, however, when we bring in these proposals so that you understand it. In the past few Council meetings we have come in regularly with a map of the country with a summary of the resources and it proved to be a little cumbersome, so it may be a good idea MRS. MARS: Thank you. wr DR. SCHREINER: This area is pretty self-sufficien Paco Federal Reportars Gre. - - / 10 “arf . 12 13 la 15 16 170 18: |} 19 20 21 24 | 25 | 93 in terms of patient flow. For example, with a transplant center at Rochester, I would be against one at Utica and. Syracuse and so forth; but I think as the central area of New York, these patients obviously aren't going to go to New York City; and it also offers the other intriguing thing; that is, it's one of the few programs we have that inter- digitates with Canada in terms of sharing. They have an ergan-sharing program with Ontario and there are several new "| | medical schools in Canada just over the border who atso-have + a substantial number of American students , by the way; and as you know, if we're going to be talking about health — resources, some people don't realize that the third largest medical school in the United States is in Italy in terms of american students, and I think Guadalajara is in the “top ten So if you want to talk about training health personnel, To think you have to look a little bit over the border, because we have a lot of people in training over the border. This is one program that does interdigitate well _ with the transplant program in Ontario. I think there are some obvious places -- I agree with John -- if you cut out RE TE SRSA AEN HOARSE SR _ two monitors you Save. 88 000; you cut out associate professor pecan eae Beef poaageonisiera baat Ent ae ene 2 | of surgery, you. save ($19,000;...but_ other, than that, _the budget as not too fat. They propose $51, 000 in salaries and we cut pansies AR cil te trsy out $10,000. DR; PAHL: Is there further discussion? T£ not, Pee Faderal Reporters, bho. : 10° il 12 13 14 15 -, 16. _ 18 19. Pao ea, ee 20 7. BBY, 94 all in favor of the motion, please say “Aye." ("ayes") DR. PAHL: Opposed? “(No Response) DR. PAHL: The motion is Gaereed. Ne aaa PHN pia ifoen SHE dA Ee cae That poneruces the business with respect to the specific applications unless staff has further comments. MRS. KYTTLE: Dr. Schreiner, Mr. Jewell and I were wondering, backing up to your Georgia redbitmendation Lf you _ ———— nan pssst could expand that for a. three-year period: of time. It' sa | three-year proposal, and with the ‘detrimental aspects of it, I think there. will have to be. some staff work, on developing budgets for the next two years. | DR. SCHREINER: I would agree with that. DR. PAHL: Before we adjourn, there is one last item of business. We would like to distribute to you at this time.a sheet which gives the grouping of regions and the ratings as provided: ‘by the Review Committee for those which — ‘were’ reviewed in the July/August review cycle, the ones under current discussion which are listed in the center of the page in a box, and the ones on the right-hand side of the page are those which were reviewed by the staff anniversary review “panel. I'd like to make two comments. First of all, the priority ratings are considered highly .confidential and : Pace Federal Reporters, Gre, 10 11 “ye: 13 14 15 t6 He . 17 18 19 20 BL 2 BS 24d 25 in the sense that Mr. Peterson described yesterday , with a “weighted mean in ofder | ‘to normalize them to the October Review July/August review cycle, you will see how they compare with _ the October/November review cycle for the applications you result of using as a baseline the October Review Committee! s are able to divide all of the applications that have been |, reviewed and rated in these two cycles into three categories . category, a tovasee point spread. So what we have is a rating of 325 to 250; again, a -75-point spread; and 95 privileged information for reasons which we have gone into before. Secondly, there are, for the July/August review cycle, two sets of ratings provided; the raw scores as given by the Review Committee and as accepted by you at the last wouncst meeting, and the adjusted scores ~- that. is, adjusted ple SE a Committee's action. So -that by looking at .the adjusted scores of the have been discussing yesterday and today; and how these, in turn, relate to “the present applications which were ‘reviewed by our own staft anniversary review panel. r would also like to indicate to you that as a ratings and adjusting the prior ratings to this ‘paseline, we which are labeled A, B and C: and which encompass in each category A, ranging ‘from 400 down to 325 -- that is, there's a 75-point range for category A. Category B would range from 96 1 Category C from 250 to 175, a 75-point spread. 2 The applications over the last two review cycles 3 | all fall within these ranges. 4 Now, the information is presented to you in this 5 |, fashion and with your concurrence of the Review Committee's . 6 | recommendations this time, we would accept these ratings as 7 | displayed as being the official ratings by Council for the 8 | applications that you have been considering. If you do not @ - 9 wish to concur in the ratings, then this is the appropriate 10 | time to bring this to staff's attention. td a I also would want to affirm again our intention, 12 | unless we hear significant news otherwise, of formalizing the 13 rating system over the next few weeks so that it will in the 14 | future be stabilized under its present format, which means - Daeo Frdral Reperor Da. 15. that at future Council meetings you will have on the aumimaity 16. sheets that come to you from both the staff anniversary revhew panel and the Review Committee the ratings da “given by 18 those review bodies, and this will be made a part of the 19 official file and will constitute one of the management. tools 20 in the selective funding process. | él . So I am asking at the present time for Council : eo ao 22 || either to formally endorse the rankings as shown provided by 23 || the Review Committee, ox to indicate otherwise and reasons 24 || therefor. 25 DR. SCHREINER: I'd just like to ask for informatidn. Pro Faderal Reporters, Phra. | 10 11 12 13 14 15 16° 17 18 19. ‘p 20° 21 | 22 eA 85 97 Just from a subjective impression that we get from the presentation, we got a pretty glowing report both from the site visitors and the reviewers on the Connecticut proposal, and yet it comes out in the B category. I think that deserves some comments. DR. PAHL: The only comment I can make is that the Review Committee, of course, viewed this particular proposal in something of a different light, as we had in this dis- cussion on the proposal here at Council, and the rating as: . provided, at least in my personal estimation, reflects the’ Review Committee's. general tenor. | | perhaps, Lorraine, you might wish to add or have: someone from staff discuss the particular rating of Connecticut. | | MRS. KYTTLE: I think that's it precisely. DR. SCHREINER: © Looking at this critically, do you see any areas of “controversy in the rating system with’ respect to ‘that. case, which seems to be at. least the one that stands out to. me ‘ag being disparate? Certainly we agreed on the Arkansas proposal. pretty generally. ‘DR. PAHL: This is a legitimate point to raise at this time.with respect to this application because of the _ discussion held by Council, and Council does have the - prerogative of altering upwards or downwards any specific _ application's.rating, and presumably, such action would be Pro.Federal Reporters, Gre. 10 11 12 13 14 15. 16 al 18 | 19 20 21 22 25 24 £5 98 transmitted back and the reasons therefor to the Review Committee. So that if you do care to take action, it is your privilege to do so. DR. SCHREINER: No, I didn't mean to take action myself, I just was curious as to whether you had spotted any areas in the rating system. DR. MARGULIES : One way we could resolve any issue like this, because it is impractical to reanalyze it here -- and of course, one can't be involved’ in a review of an area he's from -- we could easily circulate to you,, considering the fact that this is a serious question and has a great deal of meaning to Connecticut -- the kinds of rating forms which the Review Committee used, and you could fill them-out and we could tabulate the results and see what sort of an outcome we have, It's not an ideal method because the. Asgad of xatangs which are followed by the Review Committee have been very carefully outlined to them; they've had, some experience with it; and as you've already discovered, there is a changing base level over time in the rating. Nevertheless, it would be one way of getting a more valid representation of your views than to ‘accept this one, particularly in light of yesterday's discussion of the Connecticut program. DR. SCHREINER: I would have no objection to that, but I'd even be satisfied with. something short of that... Maybe when we have our commentary at the next Council meeting, if Pau Fedora Rep arlers, Gre “10 42 1a ae - 15. “16 17 18 “19 20 BY S82 . B34 24. B5 _and sort of see if they can spot any problem areas with -shatent to any one ‘of these proposals without having been a member of” the site. visit team and having a great deat more was: dust curious “as..to whether we could sort of have a retro- look at ite .° gircumstances, and bring back to you at least another judgment sone which you could then accept or reject as you please. 99 whoever is working most intensively with the scoring system just could go back over the tape of the Council discussion respect to this kind of a case. I think that would satisfy me. MR. OGDEN: It just strikes me, Doctor, that it would be very aifticult for any of us to apply that rating a4 information about the , particular Regional Medical Program, considerable background to be able to answer intelligently and. 1 weight appropriately. DR. ScuRerner: I'm inclined to agree with you. I MR, OGDEN: Well, I think what ‘You' te asking is, won't somebody on the staff please go back over the connecticut application and fetate the thing and see whether you think, on the basis of the discussion, it ought to be put someplace elsa. DR. MARGULIES : I think that would be more practical thing for us to do. As a matter of fact, we really could use the staff panel review technique on this as we have in other ste Prec Fedoral Reports, Guo. 10 11 12 13 14 15 16 17 18 | 19. || raise points, whi ch will be an improvement over what wetve | 22 ae ee 8 5. ‘experimental phase, if you will, of the rating system _ £rom the preliminary review groups the ratings, 86 that there - microphone dian' t pick that up. 100 DR. SCHREINER: I make this not out of criticism but just out of curiosity. DR. OCHSNER: Do you want a motion to approve this? DR. PAHL: Yes. We would like at this time. to have a formal motion to adopt the rankings as shown. DR. OCHSNER: I so move. MR. OGDEN: Second. DR. PAHL: It has been moved and seconded. Is there further discussion? -All in favor, say "Aye." ("Ayes") DR. PAHL: Opposed? (No Response) DR. PAHL: The motion is carried. ‘Again, let me say that we have now ended the - development. and unless something untoward happens we will be bringing to you at the time that you review the summary sheets will be an opportunity during the discussion toraise points. So there will be an opportunity during the: discussion to. had to engage in over the last two cycles. Again, ‘we re-emphasize the confidentiality if the May I thank the staff for their participation and - Pree Federal Reports, Shs 10 11 12 14 15 | 16 Las. 19 20 I 21 ee ~ 23 24 25 101 for those of you who have been able to weather the rather detailed discussion today. MRS. MARS: Before we close this discussion com- pletely, on this criteria sheet under "Process," the coordinator is weighted as eight and the RAG is only weighted | as five. Now, just why is this? It seems to me that RAG _ would deserve the same weighting. as the coordinator, so to speak. How did this evolve? DR. PAHL: The best explanation I can give is that| the Review Committee specifically requested that something of. an increased emphasis be given to the coordinator over what we had initially provided in the relative weighting for coordinator and RAG, and that the present weights reflect a™ minor modification upwards in strengthening the coordinator's - importance. ‘This was a direct result of the kinds of dis- cussion which occur by the Review Committee and site visitors and ihate they as a group felt that we were underweighting ‘the coordinator. It is a matter of judgment. MRS. MARS: Well, I don't think he should be underweighted, but I certainly think the RAG should carry as | much weight as the coordinator does, equal weight. | ) / DR. PAHL: The gestion comes, if we maintain the present overall rating system, from what do we take? _We oan, have the RAG and coordinator equal, and perhaps it should be Pee Federal Reporters, Gre. 10 ll - 12 4 14 15 1g ee 18 20. 21 || 22 | > BS: 24 talking about? | 102 a point of discussion. The Review Committee was of the definite opinion, as I've mentioned, where they wanted an extra weight given, but we are open to discussion. This is what we'd like to have. MRS. MARS: But this is staff. that, you' re talking about, Review Conmittee is staff? Is that what you're DR. ‘AHL: I'm talking about’ the actual -- I'm talking about our other consultant group’of non-staff reviewers, the official Review Committee. MR. OGDEN: May I interject: something here? Speaking from the experience I've had. ROW for five - or more years with the Washington/Alaska Regional Medical Program, . | I frankly feel that the coordinator . should have: a stronger _ rating than the. Regional Advisory Committee; and from what view I've had in some other Regional Medical programs, I think this is also true. I think a poor coordinator can pull down a good Regional Advisory Committee. MRS. MARS: I agree. I agree entirely with that. MR. OGDEN; But the strength of the coordinator really is reflected in how well his Regional Advisory Commit tee moves; the whole organization of the program, the : kind of people that he hires, the amount. of money that’ s spent, ‘the way it! s spent: and the Regional advisory Pheo-Federal Reporters, Gre 10 au 12 “13 14 15 16 17 18 | activities of the: RAG. 19 20 21 » BB 25 24 25 - Regional Medical Program lies with the core staff and very |. greatly with the coordinator of the program. . go the. route: of having real citizen involvement in this most of the applications that we've seen since I've been relate to ratings, I 'm not sure, but I think we need somehow 103 Committee meets four or five times a year, perhaps more often in some cases. There's an executive committee that maybe meets more frequently, perhaps monthly; in our case, sometimes more than that. But I frankly think that the strength of the I don't disagree with the fact that the coordinatok should have | a’ | stronger rating at all. | DR. PAL: May we have an expression from anyone else. on this Point? | MR. MILLIKEN : Well, I'm not sure it's a question of give on one more weight than the other. If we're going to activity, then I. think we've got to- deliberately do it, because we “have to make an allowance for it; and t think that involved could stand more visibility for the function and Now, maybe this is administrative and doesn't to get more importance and more visibsiity on the role and function of the RAG and how it works. in this whole deal. DR. MARGULIES: I think this particular point will require further deliberation and particularly after we bring to you a more complete form of the current draft regulations 104 1 which I described yesterday, because this will bring the 2 Council into a discussion of the relative role of the 3 grantee, the Regional Advisory Group, the coordinator, etc., 4 and I think that out of that discussion we probably can 5 create a better sense of proportion than. we can at the 6 | present time because it may crystallize some ideas which 7 have been up to the. present time a Little vague. a | “ MRS. WYCKOFF: I do think we need some guidelines 9 on that. | = MRS. MARS: I still think this is definitely Loa 3 QO 11 downgrading RAG's importance. I feel very strongly about it. le DR. MARGULIES: We will consider the question - 13 | still open. 14 DR. PAHL? If there is no further business, then a I declare the meeting adjourned, Thank you all. ‘16 | (Whereupon, at 11:55 a.m., the meeting was _ 3 iq ‘adjourned. } pga sees sera eager t EES 18 19 | 20. Ba BB BO.