Transcript of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE REGIONAL MEDICAL PROGREM SURVICH COUNCIL MTG. Rockville, Maxylend Tuesday, 17 Octcber 1972 ACE - FEDERAL REPORTERS, INC. Official Reporters 415 Second Street, N.E. Washington, D. C. 20002 (code non) s4-6292 NATION-WIDE COVERAGE “GR. 7535. @ : paw em Pce- Federal Reporters, Gne. 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HSMHA REGIONAL MEDICAL PROGRAM SERVICE COUNCIL MTG. Room G-H Parklawn Building Rockville, Maryland Tuesday, 17 October 1972 R 7535 paw Pree-TFederal Reporters, Ine. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 CONTENTS ~s2i eee = AGENDA: Texas Application» Mississippi Application Memphis Application Missouri Application Southeast Application Metropolitan New York City Application PAGE 13 16 41 73 SPARKS #1 mm cr7535 f A ce-Federal Reporters, ne. XXXX 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 PROCEEDINGS a ca tm tes ne DR. MARGULIES: Will the meeting please come to order. MR. OGDEN: The microphones are not on. DR. MARGULIES: I will project my voice to begin the meeting. We will continue with the review we initiated yesterday, and we will try to move through the applications at a steady pace, so that if there are other subjects for discussion remaining from yesterday, we can get to them. I will’ turn to Dr. Pahl now to pick up the applications, which 1 believe will begin now. DR. PAHL: I would like to have us turn our attention first to the Texas application with Mrs. Morgan as primary reviewer, and Dr. Schreiner as a backup reviewer, with Dr. Meyer being absent from the room. MRS. MORGAN: The site visit was made to Washington, Texas on August 1 and 2. Drs. Miller and Pabla were included, on the site visit team, both of whom had been on the site visit a year ago. We addressed ourselves to the advice letter of August 1971, that is, number 1, priorities must be established; number 2, subregional staff members receive more assistance; that allied health groups be - represented on the executive committee and the RAG that minority group members be \ mR “ -_ A ee- Federal Reporters, di, ne, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 represented in executive committee, the RAG and staff, and attention to assessment of mutual needs and problems to be made. The RMP program of Texas has developed priorities which were the basis for the proposed threasyear program. Objectives should be further developed in more measured terms which should be c-orrected with the employment of a qualified evaluator, a now vacant position in the program. There was increased evidence of support and assistance tp:the subregions. The cooperation with local CHPB agencies, planning groups, rather than forming local RMP advisory groups appears very practical at this time and include peripheral involvement. Expansion of allied health groups has been limited but includes the appointment of a pharmacist and so forth to the RAG. | The Texas RMP has excellent strong leadership in their coordinator, Dr. McCall. He has had opportunities to mov on to other regions, but felt very dedicated to the Texas program, and has the loyalty of the people being served. The deputy coordinator, Mr. David Ferguson, is also outstanding in his performance of duties. They do not interfere with the freedom and the flexibility of the RAG. There is ample evidence that the TExas RMP has - (3 Arce- ederal Reporters, ue. 10 Al 12 13 14 15 16 17 18 19 20 21 22 23 24 25 attracted funding from other sources for many of their. ee Of the 19 new and continued projects, le anticipated other assistance from other sources for partial funding. Of-- the 15 terminating projects, 12 of these are being funded from other sources or are self-funding and will be continued. | They have developed a statewide coordinated compre- hensive regional program which appears to be well developed, well thought out, and it has been my pleasure to see it. Progress in minority involvement has been slow. However, they have developed a positive action plan for recruiting in 1973-74, which should correct this. This was the area the site visitors felt required a greater concen- tration of effort along with greater involvement of non-positi 3 members in the RAG. The RAG members who are physicians are in private practice in the entire state, rather than the university, especially Houston-based physicians. The site visitors strongly wish to go on record for a continuing rate of A for the Texas RMP. The committee concurred with the site visitors for approval of triennial status including a development appointment. I recommended we accept the funding recommended, a ram 4 Arce- Federal Reporters, Gne. 10 11 12 13 14 lo 16 17 18 19 20 21 22 23 25 6 but that the program be reviewed in nine months for greater minority involvement in staff and RAG. If this ‘has been accomplished, the funding for years 06 and 07 will be considered. DR. PAHL: THank you. Dr. Schreiner? DR. SCHREINER: Yes, I concur. This is one of the good places where the fellows are speaking to each other. This is a significant part of the program. The significant part of the program is growing and I think the recommendation for considering the requested dollar amount for the second year is very appropriate, and I would second it. DR. PAHL: The motion has been made and seconded. Is there further discussion by the council? (No response.) If not, all in favor of the motion as stated, please say aye. (Chorus of ayes.) DR. PAHL: Opposed? (No response.) DR. PAHL: The motion is carried. Dr. Merrill, we have given you a pause here now, and perhaps we can now return to the Mississippi application. co ~ oe ‘ mm5_ XXXX APree- Gederal Reporters, ne, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 20 © You served as our primary reviewer with ~ Mr. Hiroto as backup reviewer. Will someone get Dr. Meyer from the hallway? DR. MERRILL: I participated in the site visit to the Mississippi regional medical program in June, and we found, as you know, that at the previous site visits were some recommendations. that had been addressed to change in the Mississippi program. The RAG and the program staff had been quite restructured, and the Mississippi program not only dealt with many of the criticisms and recommendations of the 1971 Site visit, but had moved forward in accomplishing other goal All of us were impressed with Dr. Lamkey, who is coordinator, and with a majority of the staff, some of whom are quite new. Some of the projects which they had already accomplished included a health expo, in which some 60 voluntar agencies participated, and MRMP provided some $8000 for seed money for this, along with a good many program staff man hours, and they had attendance of some 60,000 people, where there was considerable opportunity for individuals. We felt that coordination between the university medical center and the MRMP appeared extremely “good, with Many members staffing both groups. Here, I must confess that although it does not i i , om 2 mm6 Aace- Gederal Reporters, Ene. 10 11> 12 13 14 15 16 7 18 19 20 al 22 23 24 25 appear in the recommendations of the Review Committee or the site visit, I was a little bit concerned about this. A good many of the people on the staff of the university medical center were being paid salaries, and from MRP money, and were obviously going to have to turn to something else once this was phased out. But I think in general.we felt that they were doing as well as they could under the circumstances. They have a good renal dialysis unit with renal satellite units which have been set up, and a very active renal man, Dr. John Bower. They have increased the number of midwives in the county health improvement program, and although their previous neonatal death rate was the highest in the country, this has dropped very dramatically, I think, as a result of this program. They have an excellent stroke care demonstration center, with courses developed for physicians, who spend five days in the ward with a neurologist. They have a preliminary training program. Their coronary care unit,which was founded at the University of Mississippi medical center has trained 120 nurses in coronary care and set up a number of other coronary care .. units in other hospitals. One important part of their program has been the ” training of dental hygienists, and this is particularly oo <-> . eee 4 : cme ye web a Oe ee tee ate tea Re Lot Arce. Tederal Reporters, ne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 important since Mississippi has no dental school. Dr. Lamton and his staff, I ‘think, have gone to considerable effort to help minority professionals in obtaining hospital privileges in several instances, and although this does not appear in detail in either the site visit report |. or the report of the Review Committee, they have put in a con- siderable amount of effort in this. They have already encountered a considerable number of problems, but I think the important thing is that they have really attempted to do everything they can, and do it well. . The PRMP staff has also been involved with a preceptorship program for black medical students, in an attempt to bring black medical students back into the state,and again real efforts have been made in this direction, although there are considerable problems in this area which do not appear in the reports. Nevertheless, we did consider these problems, both with some of the black professionals involved and with Dr. Lamton and his staff. Certainly every possible effort is being made. I think it is extremely important. I think the emphasis shottld be on the fact that the coordinator has provided strong leadership, the RAG has been - restructured, they meet more frequently, they take a much greater interest in planning, and in reviewing and mm3 Prce-Gederal Reporters, Ene. 10 li 12 13 14 a3) 16 17 18 19 20 al 22 23 24 29 10 evaluating programs, and in general with a few exceptions which we will get to in a minute, they have, r think, fulfilled almost all of the criticisms that were made at the previous | site visit. . One problem they have is that the assistant direc- tor for planning and evaluation is only half time. One of the recommendations of the site visit o group and the REview Committee would be a full-time man for this position. He does have a chief planning assistant who impressed us, although he is a resident graduate with a master's degree in urban and rural planning, and as yet has not the experience, but I think he certainly has the potential for it. In general, without going into more detail on it, there were a number of additions to the staff in the restructuring of the staff, which I think represented real progress. | The recommendations of the site visitors were for funding at a level of $1,926,984 for the fourth operational year, and you will note that the Review Committee decreased this becauSe of some of the uncertainties about ongoing programs. . One particular one was a program to evaluate hospital safety in all the hospitals in Mississippi, and we \ mm9 Arce- Tederal Reporters, Ine. 10 11 12 13 14 15 16 17 _ 18 19 20 ai 22 23 24 25 11 felt perhaps this was perhaps too ambitious and not wait enough thought out, and there were several others that were considered individually. You will note also in the recommendations of the Review Committee that there is a considerable difference betwe years 4 and 5, and that is due to the fact that kidney was separately awarded and does not appear in year 4, where it is taken into account for year 5. And I certainly would recommend that we go along with the approval of the triennial application at the fudning levels recommended by the committee. DR. PAHL: THank you, Dr. Merrill. Mr. Hiroto? MR. HIROTO: I would second the motion. DR. PAHL: The motion has been made and seconded. Is there discussion? ‘DR. KOMAROFF: I had gone there the year before, an at that time and subsequently, I know there had been concern among a group of the staff that had been called dissidents, all of whom have now left the program. ' Was there any -- did this friction between a few people on the core staff and the majority of the core staff and advisory group surface? DR. MERRILL: No. I think we looked at this tr rom10 10 11 12 13 14 Prce- Tederal Reporters, ne. 15 16 17 ; 18 19 20 21 22 23 24 25 end 1 12 very carefully, having been aware of it, and talked to all of the individuals involved, both in meetings and separately at a later date, and it was certainly my impression, and I think that of the other site visitors that they had a well coordinated and satisfactory operation. | There wasn't any dissent or any difficulty any more. DR. KOMAROFF: The other question is, whether the programs for inhalation therapy and dental hygienists, if supporting them runs counter to council policy about established allied health professions support. DR. PAHL: Judy, do you want to respond to that? MS. SILSBEE: I would ask Mr. Torbert and . Mr. Van Winkle to comment on that. MR. TORBERT: Not to our knowledge. DR. MARGULIES: Thequestion is, are they leading to new programs that are leading to credentials, or is this upgrading of skills they are involved in? MR. TORBERT: Upgrading. DR. MARGULIES: Apparently it is an upgrading, so there is no conflict. ~ . DR. PAHL: If there is no further discussion, those in favor of the motion, say aye. (Chorus of ayes.) DR. PAHL: Opposed? (No response.) DR. PAHL: The motion is carried, CR 7535 #2 dhl XXXX Ace-Tederal Reporters, Gne. nN 10 11 12 13 14 15 16 17 . 18 19 20 21 22 23 24 25 13 DR. PAHL: We would like to turn to the Memphis application with Dr. Meyer as primary reviewer and Mrs. Wyckoff as backup reviewer. The record will show that Dr. Cannon is absent. DR. MEYER: As I am a neophyte, and I had to glean this without the benefit of a site visit, I would ‘like to call the staff and on Mrs. Wyckoff for assistance. There is a reapplication in the second year of a triennium. Apparently, this is because the developmental component authority had been previously withheld. This was due to a complicated regional advisory group structure. It had been composed of the Mid South Medical Center Council, which, however, did not represent all 17 counties, though it was excellent. It represented basically only 14. This did not include all 17 counties. It only included 14, and this included adjoining counties in Kentucky, Mississippi, and Arkansas. A group was formed of 36 members, and this corrected the disqualifying factor by virtue of the greater representation. This was also assisted and avoided .a lot of complications administratively by the multi state involvement. The current funding was $1,627,000, and the new RAG requested $2,367,127. The staff has recommended $2,252,000. This was to support the Arce- Tederal Reporters, GFne, 10 11 13 14 15 16 17 18 19 20 21 22 23 24 25 14 current program. The developmental component, $162,700, and to su- pport selected new activities, including ambulatory health care centers in the neighborhood. This was for a $236,300 amount. The remaining was for selected activities under ‘contract, requests of $225,000. The recommendation, the reduction, rather, was recommended because the review staff felt that this newly formed RAG had not as yet been able to develop sufficient data in their plans for more members of the new council. - Apparently, there had been considerable discussions regarding the expanded community health service activities and emergency medical service. Both of these were reduced. It is my impresion from reading over what was submitted to me that this is an excellent program with a very competent group of hard working people in it, and it certainly should receive . support. | I therefore make a motion that the committee recommendation that the developmental component and the $2 million be approved. MRS. WYCKOFF: I will second the motion. I only want to make cne comment. I hope so much that every effort will be made to get Dr. Culbertson Ms. Gh Pee- GTederal Reporters, Ine. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 L5 to employ an assistant. for himself, because I feel he is a very overworked man and it is hard to administer the medical program of Memphis. It has so many agencies. They really have:done a marvelous job of helping that area apply for Federal funds, and there are cooperative relation- ships, but Dr. Culbertson is overworked terribly, and he © needs an assistant, and I hope very much they will do something like California, and get an assistant who will - ge a representative of the very large black population if at all possible. DR. PAHL: Thank you, Mrs. Wyckoff. ' A motion has been made and seconded to accept the committee's recommendations. Is there discussion by the council? DR. MC PHEDRAN: Will they have enough money with this funding recommendation, Mrs. Wyckoff, to do what you suggest? “MRS. WYCKOFF: To employ the assistant? DR. MC PHEDRAN: I mean to attract somebody to the job. . MRS. WYCKOFF: I think the budget contains enough to employ the new assistant. They do not want them to increase staff otherwise, because they have heavily overloaded, but this is a very important position. DR. PAHL: Is there any discussion on the part Pree- Federal Reporters, Ge. dh4 XXXX 10 11 12 13 14 15 16 17 18 19 20 21 22 23 29 16 of staff relative to this point? “MS. KYTTEL: The staff's recommendation of 2.2 took into consideration the need to employ a deputy. This program's funding has been at a level that really has not permitted too much movement in that respect, and also, hopefully, funds for them to move into the emergency medical services systems area. $2 million will make them make hard choices. $2.2, staff felt, would permit them to move into two areas. They may have to make a choice of one. DR. PAHL: Thank you. Is there any further discussion by council? | If not, all in favor of the motion, please say aye. (Chorus of ayes.) DR. PAHL: Opposed? (No response.) DR. PAHL: The motion is carried. Will someone please get Dr. Cannon in the room? Dr. McPhedran, I believe, we might now have your report to the council on the Missouri site visit, if you will, please. DR. MC PHEDRAN: This a site visit on 18 September. The purpose of the visit was not to review any new applications, but to go over the progress of the Missouri | ahs Pree- Federal Reporters, Gre. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 17 regional program. The progress, we hoped, this occurred since the last site visit and the last recommendations. Ms. Silsbee and Dr. Farrell came along with members of the review committe, and we were privileged to have Dr. Calagreeno serve as a consultant on this site visit, which was.for one day a kind of continuous exchange of inquiries and advice, sort of:like a dialogue feedback session with all of the pain and anguish that that entails. This is now in the second year of the Missouri regional member program, in the second year of a triennial award, and the triennial award, when it was made, was made without developmental component, because the program in staff, organization and in organization of the regional advisory group, did not seem strong enough to warrant developmental components, and that still seems to be the case. . In addition to that, we have differed with the Missouri regional program that we, the site visitors, and RMPS , about the value of some expensive computer projects. One is best known as the BASS project, a computer project in a physics office in Missouri. It seemed that the use of the equipment and the results of it-really didn't justify the enormous amount of money expended on it, and in addition to that, technical reviews _of , for example, dh6é APrce-Tederal Reporters, ne. 10 11 13 14 15 16 17 18 19 20 21 22 23 24 25 18 the kind of equipment being used as time went on made us feel that technologically, the project really wasn't very sound. That is in addition to the fact that it wasn't even living up to its potential. Now, a lot of favorable publicity had come to the program from these projects, but the RMPS site visitors, review committee, and council were not much moved by this, and we had recommended repeatedly and earnestly that those projects be terminated. This had been very clear before the triennial - award was made, but even after the triennial award, the program came back with a request for supplemental funds last fall to continue to support these activities. This so exasperated the review committee that they wanted to withdraw triennial status, but we didn't go along with that, but did feel that additional site visits would be useful in helping to get the message to the region. Meanwhile, ‘the region has gone to health services and mental health administration through a contract mechanism. I was going to say so much for that, except for the fact that the regional advisory group leadership apparently misunderstood, at least this was apparent in f our site visit, where this additional ‘support came from. i dh? Pree-Tederal Reporters, Ine. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 19 They thought it had come through the RMPS granting mechanism, that we had relented after all these advises, but we gave them to understand that it didn't come through the RMPS granting mechanism, this additional support. These computer based projects and all of the diversities of opinion that arose, it seemed to have a horrible fascination for site visitors from RMPS, but it is really only a particular manifestation of what has seemed to be a basic problem with the program. We felt at this time that the program staff was beginning to seek out problems in the region beginning to look for solutions to these problems whereas previously they have taken the position that they should wait for projects and new activities to be submitted to them. The argument has always been made that this has been done so as not to hinder the local flavor of any project, but it has always resulted in the lack of any cohereent direction to the program activity as a whole. Now, the very large program staff is beginning to work on setting priorities, goals, and objectives, and they are looking around for ways to implement them. There are several projects that could be cited as examples of this. The one that is most often cited is the so-called Green Hills project, which is a series of cooperative arrangements that has been fostered between a group of Ace-Tederal Reporters, ne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 20 of hospitals that were having a great deal of difficulty in surviving by themselves. This is the kind of thing that they are going to use as a model, apparently, throughout the region, and it is a good model, although, again, Mr. Toomey, of our site visiting team, who is director of a hospital system in Greenville, South Carolina, Mr. Toomey was in a position to make some very intelligent criticisms even about this fairly successful project. Whether or not a staff of a program, a program staff, which has been built on the old policy of waiting: for things to come in from the region and then working them up into some kind of a project, whether or not they will be able to change direction and provide direction of the program more from the center, is another question we weren't really sure about. In connection with this, we were astonished that the director of the program is there only 54 percent of the time with the program. The director has assumed another responsibility in a consumer education program, part of the university extension activities. | We though that this waS an inappropriate thing. We thought that he should be full time with the regional medical program, and we said as much. We don't know how this is going to be resolved, e- Prce- Gederal Rehorters, Gre. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 ‘21 although the director said if he had to choose between : the two activities, he would choose the Missouri regional medical program. But that he would have taken this step and taken on this additional responsibility, I think, is a reflection of the fact that he and the staff as a whole, I guess, didn't really understand how concerned previous site visitors were about the lack of coherent direction of that program. I think that is really the message I want to bring to you about that. Now, also, the regional advisory group is not really representative of all of the ‘forces. that. should be. There is no VA representation on it. CHP representation is also absent, but there is no particular criticism, there being no necessarily critical size for a regional advisory group, but it lacked some of the official representation that it should have, and also minor representation was notably lacking. On the other odds and ends about the program that we felt could be criticized are, first, their review process, which is slow and cumbersome. Second, their lack of an evaluation section. They need that, but they know they need that, and they are working on that, and also working on having some measurable sub- goals and objectives that could be used by an evaluation dh1o Dce- Gederal Reporters, Gne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 22 team. So, in summary, we thought that we were able to get across to them these continued criticisms. We do see some evidence of improvement in the program as a whole. I know I haven't said much about that, but we did see in the program staff efforts to develop measurable objectives that they were looking toward a new day, and also we found that the subregional directors that they have in the state were a competent group of people and were probably better able to assess the needs of the subregion than people have given them credit for when we began the site visit.. So we learned something from them, too. There is no new money here that we have to talk about. We are not talking about changing the grant or taking anything away, or adding anything on. We are simply giving a progress report on recommendations that we made before, and in short, some progress has been made. We hope that it will be better, and we do think that the diretor does need to be full time, among the other recommendations. DR. PAHL: Thank you very much, Dr. McPhedran. I believe the topic is open for council discussion? MRS. MARS: Would the coordinator, if his salary were raised, probably not consider another job? Are they paying too low a salary, and was he forced into taking that position? Pree-Tederal Reporters, Ine. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 23 DR. MC PHEDRAN: I think the salary was about the same. It was a different division of time, and a different source of money. I think he was asked to take on this additional responsibility, or it was suggested that he was the right man for the job, and indeed he may be the best man for the job. It is just that it seems that doing .both of them would be clearly too much. DR. SHREINER: What is the size of the contract? DR. MC PHEDRAN: You mean for this continuing education? DR. SHREINER: No, the direct contract. DR. MC PHEDRAN: I don't know. MISS HOUSEAL: © $150,000. DR. “MARGULIES: Donna, could you go to the microphone? Perhaps it would be a good idea to cover the details of this contract for the council. MISS HOUSEAL: We are presently extending the ‘contract to the end of December to allow time for the National Center for Research and Development to develop a new contract which will pick up support for this activity, so I think RMP's days with this activity are soon coming to an end. The support, as I gaid before, was about $150,000 Prce- Federal Reporlers, One. Qu Nt 10 li 12 13 14 15 16 17 18 19 20 21 22 23 25 for six months. DR. MARGULIES: Thank you. DR. PAHL: Mr. Hiroto? MR. HIROTO: Dr. McPhedran, if this were not merely a progress report, would the visitors have made specific recommendations? , DR. MC PHEDRAN: You mean would we have made recommendations, for example, about awarding triennial status now? MR. HIROTO: Yes. DR. MCPHEDRAN: I don't know. I guess maybe this year we maybe have been more easily persuaded of the review committee's position on triennial status, that it wasn't appropriate. I guess s would have been. It really didn't come up, and we didn't discuss it. mea-1 _ . CR 7535 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 MR. OGDEN: ‘This raises a question possibly for my own education ~-- if we have any authority to withdraw a trienniel grant once it has been given? DR. MARGULIES: Yes. This was the recommendation last time of the Review Committee, but .Council felt they did not want to uphold that recommendation. DR, MC PHEDRAN: Mr. Hiroto, maybe I ought. to backtrack on that a little bit. I would really have to think about that a lot before making that recommendation, I do think there are several things about the program staff's activity which have been very helpful, and I do think the subregional directors were pretty good, and doing a creditable job. I think the direction from the top has not been good, and I wouldn't hedge on that at all, and I think that maybe that is the principal difficulty, and maybe this having to make a choice now will resolve that. | I don't know whether it will or not. MR. OGDEN: What have you done; have you written him a letter; has a letter gone to them? DR. MC PHEDRAN: I believe a letter will go to them after these deliberations now. DR. KOMAROFF: Did you speak with any of the members of the Advisory Group or’ the grantee about the top leadership, and did they seem to appreciate it? mea~2 10 11 12 13 14 15 16 17 18 19 20 21 22 24 25 26 DR. MC PHEDRAN: No, we didn't do that this visit. I think that that is probably something that should have \ been done, looking back. DR. MARGULIES: This site visit became altered practically in midflight, because it was the recommendation of the Review Committee and the Council initially that the site visiting ought to explain in the clearest possible terms the great concern which the Review Committee and Council had with the program. In the interim, the program began to realize that the Council had been very serious and very determined about what was to be done out there, so before the site visit actually arrived, they had undertaken some striking changes, which you have just heard about. Then the site visit ended up being of a different kind than we initially intended. | DR. PAHL: Judy, do you have anything to add? MS. SILSBEE: There was a problem for several years with the structure. When the structure was set up originally, there were three different groups, and there was a Liaison group with health organization; there was the project review group, and then there was a 12~-man group at the top. _ At one time they would say this whole three~group body was the regional advisory group, and finally they mea-3 10 11 12 13 14 18 16 17 18 19 20 21 22 23 24 25 27 decided that the 12-member group was the advisory group. I think the site visitors made clear that once having made this determination, they should stop worrying about the other groups and make the 12-member group big” enough so that it met all the requirements for a regional advisory group. | As it now stands, it doesn't. It doesn't have some of the representation that is required. The site visit team's discussions with the members of the regional advisory group was probably the most helpful part of the meeting, because they were able to explain to the regional advisory group what Council was expecting of them, and I don't think up to that point the regional advisory group had really appreciated their role, DR. PAHL: Is there further discussion by Council or staff? a DR. MARGULIES: I would like to raise another issue related to this while we are at it. Mrs. Curry wondered yesterday if we could at least raise some of the problems involved with the territories in Missouri, in the bi-state program, and . Illinois, and not with the intention of being able to resolve them here. I would at least like to point to the fact that they are going to require some special attention in all mea-4 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 28 likelihood. The problems are different from those that we i addressed out in the northwest, and they consist of a real conflict between the Illinois program and bi-state, which is rather difficult to itemize, “but which consists for the most part of an understanding on the part of the bi-state program located in St. Louis that it has responsibility for those areas which are normally a part of the medical service area of the large urban center that St. Louis is with a rather remarkable collection of medical facilities of all kinds. This causes problems because it extends into Illinois in areas which are now a part of, or a projected part of the Illinois medical education system, including the Capital of the State in Springfield, where there are RMP activities in bi-state, and extending further on down where there is a projected medical school as part of the University of Illinois system. Thus far, there has been the feeling on the part of the coordinator and bi-state that they can work this arrangement quite easily, and a feeling on the part of the coordinator in Illinois that it is not a tenable situation and needs to be resolved. Added to this is a growing pressure coming from Al Snopes, who is in the Office of the Governor in Illinois, omen ty -. mea-5 10 11 12 13 14 16 17 18 19 20 21 22 25 29 saying this is creating problems with CHP A. and B agencies, and needs to be resolved by central direction. It seems to me they have in their correspondence in Illinois, that they have pointed to problems that might exist rather than those that do exist. — Nevertheless, there is great uneasiness. This also raises the question, and Alex, you may have feeling about it, as to what role the Missouri RMP might play in the resolution of this, because it might include -~ I am not suggesting it -- responsibility on the part of the Missouri RMP for St. Louis if any rational change was to be suggested. I think you might easily respond to that question, but I am willing to raise it for your consideration at this moment. DR. MC PHEDRAN: Well, I don't really remember hearing much, or having much of a feeling that there was any contest between the Missouri RMP and the bi-state RMP over who was going to represent St. Louis in this activity. I think that although I visited them just a couple of weeks apart, I didn't get that feeling. Maybe I missed something here. . DR. MARGULIES: No, I simply wanted your confirmation. I don't believe that is an issue -at all, but I wanted to be sure we raised the question. mea-6 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 | 30 DR. MC PHEDRAN: I understood the differences between bi-state and Illinois exactly the way you stated it, andif the lines had to be drawn so that all of Southern Illinois is included in the Illinois RMP, then the question would be what would happen to St. Louis? Is that it? DR. MARGULIES: That would be a part of it, and whether it makes sense to do it that way. DR. MC PHEDRAN: It doesn't make sense according to the original way that regional medical programs were set up, because this is evidently a regional bi-state. They made a very good case for that. How. far north you go in Illinois in the region, I don't know. DR. MARGULIES: That has been our attitude, and Snopes’ attitude was a reasonable one in the last letter he wrote which came in two or three days ago. He feels that those areas being served by bi~-state can work perfectly well in the CHP agencies in Illinois. They don't have to be in the State of Illinois, if that is the area of service, but it may require us to have some kind of visit with the people out there to try to reach an understanding so that they don't jostle one another as much as they are attempting to do at the present time; DR. MC PHEDRAN: I can understand the political - mea-7 10 11 12 13 14 15 16 17 18 19 20 21 22 24 25 31 importance of whether Springfield is in the bi-state or the Illinois regional medical program district. I can understand why the people in Illinois would be concerned about that, but if it is looked at as a regional medical program, | bi-state has a good reason for being. | DR. MARGULIES: Dr. Schreiner? DR. SCHREINER: I have toured that area as far as the kidney facilities are concerned, and served as a consultant to the new medical school when it started, and there is no question that the kidney people were related to St. Louis, but financially, they were getting money from the State of Illinois; despite the fact that they haa a very high respect for the administration of the Illinois RMP, they definitely expressed, everybody I talked to. definitely expressed a desire to stay with St. Louis. DR. MARGULIES: It would be a little absurd to ignore the fact that for generations St. Louis has been one of the great medical centers of the country, and is going to continue to attract people, because of its great skills, whether it is in the kidney field or elsewhere. It is a city which has two medical schools, many great hospitals, and has for years been one of the leading centers of the nation. It would be unwise not to take advantage of that fact. So, I think it is really a matter of working around the facts of life rather than trying to mea-8 10 11 12 13 14 15 16 17 18 19 20 21 22 24 25 32 change them. Mr. Milliken? MR. MILLIKEN: i happened to be at a meeting with Dr. Snopes about 10 days ago, and this was brought up, and I just happened-to have in my briefcase a copy of the subareal contract which we used in the three-state Cincinnati area, Indiana, Kentucky, and Ohio. He felt it was the answer to the problem, and he was going to use this in that area as an example of this interrelationship which could go both ways, and tie it down to specifics. This may help. DR. MARGULIES: For some reason, I think 1 Cannon wants to be in this discussion. DR. CANNON: I gather you detected my uneasiness. I was going to wait until later and ask that we discuss the presentation by Dr. Stone, but in your remarks, Harold, I think it is appropriate that we discuss ee now that for a long time this Council has talked about, the interests of the Administrator of HMSHA, and the regional medical programs and its intent. One of the original concepts was that the regional medical programs was not going to interfere with normal medical referral patterns. Dr. Stone's presentation stated in the second paragraph, emphasizing the attributes of the regional medical program, number 1, “Its decision-making powers have a f mea~9 10 il 12 13 14 15 16 17 18 19 20 21 22 only states and subregions of states are singled out as 33 been decentralized to the final level in most cases. That is, to the states or subregions of the states." Now, we began on the premise that a region was a logical geographic unit, and by logical geographic unit, we meant it was the region defined itself by its wholesaling, marketing, its purchasing, its utilization, its news media coverage and so forth, as well as its medical referral . patterns. | Gradually, over a period of years. that I have been on the Council, I have detected, and it was easily detected, that there is a tendency to move this into the. states, the state government process, and I believe that such an attempt, no matter where it stems from, would be to the detriment of the regional medical program. . I think that this Council, before this document goes out, and there are other points I wish to discuss, .. . should modify that first statement so it doesn't appear that being attributes of the decentralizing process. I am very sensitive to this. We started in Memphis because of the Mississippi River. It began many years ago to be a region, ‘North Mississippi and Eastern Arkansas and Southeastern Missouri; Western Kentucky still reads the "Commercial Appeal" and listens to WMC ‘and watches WMC-TV. They come to Memphis to buy their clothes; they trad¢d poe 10 11 12 13 14 15 16 17 18 19 20 21 22 24 34 on the cotton market, and it is a designed geographic unit so far as the people and the way they associate themselves with the center. I can see that St. Louis is in much the same situation. It would be wrong at any time that this Council creates the feeling that there is a prerogative for the state government or otherwise, health officials in the state, to assume the responsibilities that this regional medical program originally set out to do, and that is to enhance the normal referral patterns, and not to destroy them. I really think that this ought to be clarified. DR. MARGULIES: Dr. Brennan? DR. BRENNAN: There is a little problem with this position, unmodified, and that is that after our regions were set up, the CHP program came into being, and one of the directives we have had, or obligations that we have had, was to relate RMP to the CHP A and B agencies. Now, they are all state agencies. So, we have a little knot here, and I don't know exactly how to get ~, around it. Arce- Gederal Reporters, Ene. jonl 10 11 12 13 14 15 16 17 18 19 20 21 22 23 20 35 DR. MARGULIES: Mr, Millikan, would you like to comment? I want to remind you that Sewell is Director of CHPA Agency in Ohio. DR. MILLIKAN: In the legislation for CHP there is a considerable number of paragraphs relating to the fact that CHP is to establish, where necessary, interstate CHP organizations. We have one of the first and the best in Ohio which is the area of Cincinnati. It is six counties in Cincinnati. DR. CANNON: I wish to correct that. Memphis was the first. DR. MILLIKAN: We will stand with that. There are four in Indiana. Through some adaptations that I mentioned before this has worked exceedingly well, and the only problem has — been that it was soon dissolved in the regional office where we had to go to two regional offices to clear things because Kentucky is in one regional office and Ohio and Indiana are in another. But this was quickly taken care of and the federal government named one regional office, the ‘Chicago regional office, to be primary. So the other region just gets their information from them and I would offer the Arce- GTederal Reporlers, Gne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 29 36 RMP~CHP relationship in that area as one of the best in the country and two of the strongest -- one of the strongest -- RMPs and B agencies, DR. MARGULIES: Is there any other comment on this issue? . DR. CANNON: I want to hear your comments on Dr. Stone's first listing, those four things now, because what is going to happen to this document of Dr. Stone's? MR. OGDEN: I wonder, Dr. Cannon, if we could hold that discussion until a little later and try to finish the agenda because I think a great many of us have comments and discussion we would like to raise about this. DR. MARGULIES: Is that all right with you, Bland? DR. CANNON: Well, the only reason I mentioned it here was that it seemed to apply to the bi-state problem, and this is the reason I brought it up. I will be glad to defer it until later. DR. MARGULIES: On that particular point as to what is going to happen with it, the document that you have represents a presentation which was made to the council, It provides them with information from the administrator. The way in which the council responds, of course, depends upon its judgment. . I don't know what the implications are regarding ao ge, i ) i } Arce-Gederal Reporters, ne. jon3_ 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 37 the geopolitical boundaries of regional medical programs and if there is some doubt about it or if the issue needs to be raised and clarified from the point of view of the council I think it is quite appropriate that the council act in whatever way it thinks it should. There is only one problem involved in it and I think that is why we should wait for further discussion. That is that this is no longer a part of the public agenda. As a consequence, any action of an advisory kind which affects policy cannot be taken by the council at this time but we can set up some other mechanisms to make what we do appropriate to the existing laws. We can get back to this discussion and then perhaps set up an executive group or something of that kind to do whatever you think needs to be done. | If that is all right we can go on with the reviews and then come back to this discussion. It won't be long because we have very little else that we need to take review action on. DR. PAHL:. The remaining applications are to be found under the pink tab at the back of your loose leaf book and they are three applications which are requesting support under our 901 authority. ; | Two of them are somewhat similar in nature and have been assigned to Mrs. Mars and Mr. Ogden and the third BPee-ederal Reporters, Gane. 16 17 18 19 20 21 22 38 one is a specific kidney application that has been assigned to Dr. Merrill and Dr. Musser. Before going into these, though, I would like to make two remarks. The first is that in the case of the applications from the southeast interregional program and the northeast interregional program we ao not believe it. rs for council members to leave the room because of conflict of interest because in these particular applications it is treating an administrative matter and we believe this conflict of interest can be waived. However, in the case with the kidney application from New York, we will ask Dr. Watkins to absent himself from the room. Also, I think to have a proper introduction to these applications we would like to have Dr. Margulies give you just a few words since this will be a new type of application coming before the council. . DR. MARGULIES : As we said earlier in the meeting, we have not completed the detailed description of how the 910 applications are to be carried right now, but we are able to act on a pro tem basis and have, as I think you know,: utilized the 910 section in the past in providing various ranges of grant Ss. What is being considered today in the first two i applications, particularly in the first one, is an affirmatio: Phee- Federal Rehorters, ne. 10 1i 12 13 14 15 16 17 18 19 20 21 22 23 25 39 by a proper procedure of something which has been under way for a long period of time on an informal basis: The southeast coordinators have had as a general agreement among them a sum of money which they utilize to employ an individual who acts in the common interest of the southeast coordinators. He coordinates their inter~program interests, provides meeting arrangements for them, develops programs and in general serves the southeast interests which are of special interest to them. this is ranged over a very wide number of subjects. This particular sectional grouping has begun to grow and it has begun to show some real promise. It has had a varying kind of strength, but for the last few years the regional medical programs have recognized the fact that there are somethings which they can do, acting together, and the geographic regional basis which enhanced their common interest. They, among other things, select from the various . geographic sections a representative to a steering committee | with which we meet regularly, providing us with an opportunit to hear from them and to provide information to them in a rapid and informal manner and to develop a kind of network of ‘information which is remarkable. } We can, if we need to, get a question out and an t Arse- Gederal Reporters, ne. jon6 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 40 answer back from all 56 regional medical programs sometimes from the areas in a period of less than 24 hours which is unusual for the federal government. This sometimes provides us with some distinct advantages in tight negotiations. Beyond that, it provides an opportunity for them to gain a level of understanding which is more explicit than you can sometimes achieve by waiting for formalized documents. The southeast group has had in their employ Mr. Youngerman for a period of, I would imagine, in excess of two years. In reviewing the arrangement that they had for his employ it appeared to us that this should be formalized in the form of a 910 application so that there is a clear understanding of what he is there for, what the funds are to be used for and a way of handling it in a grant administration manner which is appropriate to the circumstances, _This will be the first one which we will be acting on. The other one is to consider a similar arrangement in the northeast, but they have not actually experienced having an individual in office up to the present time. They understand what they want to do, but they haven't had the arrangement that the southeast has had. I think that is all. DR. PAHL: All right. Why don't we turn to the Dee. Taderal Reporters, Gne. 10 11 12 | 13 14 15 16 17 18 19 20 21 22 23 24 25 4] southeast application and have Mr. Ogden present it and Mrs. Mars as backup reviewer. MR. OGDEN: I am sure that all of you have had a chance to read the material that was sent out, but before reaching a conclusion on the advisability of funding it I felt there was a series of questions that ue should ask and answer to ourselves. Some of them may be questions raised out of my own lack of knowledge of relationships which may exist, and if that is true I apologize for using the council's time for my own education. But I have written down a series of questions which seem to me to be pertinent to this type of an applica- tion and I would hope that we can answer them rather rapidly. My first question was this: would this proposal duplicate the functions of RMPS staff? I think the answer to that, obviously, is that there is no one on the staff doing this precise job. “DR. MARGULIES: I think that is correct, MR. OGDEN: Then, should this be an activity of the coordinators, or should it be an activity of RMPS? Where will this man receive bétter control and direction among the coordinators which is a loosely organized group, or from RMPS? Should the activity -- well, that is all right. I was going to say if it duplicates an already existing a mom St A PArce-Federal Reporters, Ine. jons 10 11 13 14 15 16 17 18 19 20 21 22 23 24 25 42 activity, should this be terminated, but this is beside the point now. How would this individual here contemplated and, of course, is he already on the job, so perhaps that has been worked out, but how would he relate to the RMP &taff people in the offices of Regions 3, 4, 5 and 6? How does he relate to the operations branch of RMPS once he becomes something more formal than he is. Now, if these questions can be easily answered having been thought through in the development of this application, then I would recommend the three-year funding for this. That is, with annual reports to the council on its progress and accomplishments, but I would like to have some discussion from those who were more knowledgeable than I about the relationship that the individual now has. I know Mr. Youngerman, and have worked with him on one or two things. I want to know the relationship he ‘has directly with the RMP staff people within the offices of Regions 3, 4, 5 and 6, and how you relate to the operation: branch, what sort of more formal relationships would be important and necessary. Miss Silsbee wrote me there was about a two and a half inch backup file on this which fortunately nobody sent me. I am sorry that I have not had the opportunity to review that because some of these questions might have been answered in it CR 7535 take 5 Paco. Federal Reporters, Gue. ot, 10 11 12 13 14 15 16 7 18 19 20 21 22 23 24 25 43 DR. MARGULIES: I think that one could reasonably say, Mr. Ogden, that there would be good reason to meet that southeast area need for somebody to coordinate their activities by somebody supported by RMPS, who is located there and who has a responsibility to RMPS as well as to them. As a practical matter, it can't be done. We don't have those kinds of resources, and the staff is being nibbled at, rather than otherwise. On the other hand, there is a different kind of generation of interest in having him, because he repre- sents their choice of someone to work with them for interest¢ that they identify in common. I know that he has been of great assistance to them in organizing major meetings on such issues as regional kidney dialysis and transplant activities, quality assess-~- ment, and assurance, which they address together in the Southeast group, and he has certainly had a hand in making the sectional meetings in the Southeast clearly better than they are in any “other part. of the country. He can develop an agenda for them, find out what their common interests are and produces a sense of commonality in bringing them together that couldn't be produced otherwise. Again, this could be accomplished by people dor 2 Arce: Federal Reporters, ne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 44 operating out of our staff, but that is.a remote possibility. There is the possibility that an individual placed in that position will become not merely a coordinator of activities, but something more aggressive, a spokesman for them, going froma level of mild interest to ain aggressivt interest and beyond, and I think that it is very important that it be understood that he serves the interests of the coordinators locally in terms of their professional and organizational concerns as Regional Medical Programs, and does not concern himself there or anywhere else with such issues as those that might appear to be lobbying activities or something of a similar kind. I think that would be highly inappropriate with the use of RMP grant funds and probably inappropriate under other circumstances as well. I think perhaps, Lee, you may want to comment on this. MR. OGDEN: I would like to know how he relates now to the RMPS people in the reginal offices. MR. VAN. WINKLE: I can't speak for all the region: offices. I know that he and the Atlanta REgional Office work hand in hand and most of their programs are planned together. As far as staff, he keeps us fully informed. He has been very supportive, and I would say that from his ! base, he could be much more flexible than we could on staff. dor 3 foo. fon Arce- Gederal Reporters, Gne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 45 I think he is able to do things we are not, and working with the RPS . DR. MARGULIES: Dr. Schreiner? DR. SCHREINER: I have two questions. Although I admire the success with which this particular individual has worked, particularly in the kidney area, I think there — are a couple of bothersome questions. One is, does this give this gropu of regions unfair advantage in a granting program where there is rapidly shifting directives, and rapidly shifting goals and constantly changing horizons. Obviously, if one group of regions has an incite into the communications. mechanism that other groups don't. that bothers me a little bit, and the second thing is that the biggest criticism against the RMP. is the excessive layering between the consumer and the staff, and isn't this yet another layer? DR. PAHL: May I respond to the first question concerning the advantage which accrues to this particular region? It is true. that at the present time there is this advantage to the one region in that the individual has been operating there for perhaps two years. The fact that we have an application from another region indicates there interest in having this type of position available to them, and we would presume that there could be’ over a relatively Arce- Tederal Reporters, d, ne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 46 short period of time five such individuals corresponding to the five regions, five multi-regional units that the coordinators themselves have defined. So that it is quite possible we would have a total of five such positions with two applications for these positions b efore us today. Relative to the layering between RMP and the . consumer, I believe it is fair to say that this does not represent layering, that this individual is working with and among the coordinators on a professional basis, and that he does not interpose himself, either as the individual or the position, that is not interposed between the Regional Medical Program and the consumers and clientele and others. Harold, do you want to comment on that point? DR. MARGULIES: Dr. Brennan? | DR. BRENNAN: I have already said this about it going to five, I was going to remark that it would probably go to five, plus I am sure a couple of secretaries and an administrative assistant, and some office space, and a heck of a lot of travel money, eventually, and I think this is going to add to the administrative costs of this program substantially. | I think you can't do this without realizing what Dr. Schreiner was implying, that you have created a new rank and office, and now to talk about supporting that out of 910 funds, I wouldn't think that 910 funds would be the Arce- Gederal Reporters, Gne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 47 appropriate place to get this. I don't think this is an inter-regional program activity, or developmental activity, per se. I thihk this is clearly an administrative assistant to the coordinator. I think if it is going to come from anywhere, it ought to come out of our RMPS administrative budget, but not without the realization tree we are not talking about only one fellow, we are talking about five people, and by the time you get through, you will have assistants for each of those guys. MR. OGDEN: Mike, might I comment here that yesterday, we had Dr. Milliken reporting on the problem that developed among the Mountain States programs, and I had the feeling that had there been this type of man around, that problem might have been avoided. | And I can see some real benefit from having someone like this. I think the question you riase as to what 910 funds are intended for and whether this is the proper use of them is something that we ought really to perhaps discuss a little further before we vote on this. I am not sure that I understand precisely what the 910 funds are permitted to be used for, whether we can use them for this type of personnel, or whether it is something limited to a grant which is sort of run through and has been approved by a cooperative arrangement between dor 6 Pree. Federal Reporters, ne. 10 11 12 13 14 16 17 18 19 20 21 22 23 25 48 two Regional Medical Programs. So it would be Sr a grant purpose rather than a personnel purpose. | DR. MARGULIES: This is appropriate for the 910, which has a fairly broad description, but it does meet the requirement of achieving on an inter-RMP basis something which cannot be accomplished by the individual RMP and which is a common concern. In this case, it is to provide a framework within which the professional achievement of the combined RMPs can prosper. I think Dr. Brennan's point is perfectly valid. It would be a good thing if we provided this ; support out of administrative funds. If you look at the record with Federal employment — in general and RMPS specifically, we are in 1972 approximately, at one third of the level of employment we were three years ago, and the present staff level has been reduced during the past year below the official level, which was budgeted, because there have to be people placed in other kinds of activities, so that we are more likely to have fewer people available in the future than more. So the question of whether this should be done by RMPS placing people there is a reasonable one, but not a practical one. There isn't a chance that we would be able to do it. Mrs. Wyckoff? i dor 7 BAce- Gederal Reporters, ne. ae on 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 49 MRS. WYCKOFF: If he is on the central staff, they certainly wouldn't have that feeling. But if he is under 910, they might feel that they really did have their own man. DR. MARGULIES : The decision is theirs, the employment is theirs, the management is theirs, the super- vision and hiring and firing is theirs. Dr.. Brennan? | DR. BRENNAN: You know, if this kind of adminis- trative facilitative function, which is what I think it is, it isa coordinating facilitative function that belongs properly with administration, if that can't be differentiated from 910 money, then theoretically, the whole administration here in Washington could be paid for here with 910 money. There has ‘to be a chord there, and we haven't stru on it in our discussion this morning. If this man is this important to the regions, and after all, it is one man's salary here, you have got five regions. I can't imagine any of them going broke by putting in two or three thousand each with the approval of their regional advisory gorups to provide this man and his office and travel time. MR. OGDEN: That is exactly what they are doing right now. DR. BRENNAN: But that is what I would like them dor 8 Arce- Federal Reporters, ne. 10 11 12 13 | 15 16 17 18 19 20 21 22 2 24 25 50 to continue doing. My own idea through the years of the 910 funds has been something different. It has related to such things as the provision of educational materials, because the thing could be done better for multiple regions, or nore economically, or sensibly than trying to set up the same operation in all regions. I think inter-regional cooperation in some areas is absolutely right and functional. I think that is where 910 money should be, and if what these coordinators need is this kind of help to do a better job, then let them continue to make an invest- ment in it. DR. MARGULIES: That is precisely the thing they have to do, and you are talking about the same money, Mike, whether they do it invidivally or through a mechanism. It is the same pot of money, but it has been done in an irregular fashion, because they are diverting grant funds into an activity which should be recognized by this council, and either you accept the idea, or you don't, and if you accept it, the only mechanism available is 910, because it covers the inter-regional program activities. You cannot give them oney for aid programs or a series of them, and then take X amount of that to support the activity without circumventing the grant process which is being utilized. ~, dor 9 Pee- Gederal Reporters, fi, ne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 51 It is a way of looking at it and deciding whether that is what you want to have done or not. It is all the same money. DR. BRENNAN: What I was saying, Harold, was this, I think if the reginal advisory groups in all five regions had to continuously reindorse’on.an annual basis the continuance of that function, that it is going to get a local evaluation that will be a little wider than just _whether the coordinators feel this guy is useful. “Taking it into 910 might not allow for that. I don't see why this would be a legitimate expense out of what we used to call core staff, or even developmental funds for. ‘our regional advisory group to authorize, to pool in, to help get such a fellow. ee DR. SCHREINER: There are all kinds of organiza- tions: that don't have regional chiefs, and when they need to communicate with each other, they have a meeting, or elect a committee, or they vote one of them to perform the communication. It seems to me to be an administrative thing, and I think we are open to criticism, as Mike says, if we really haven't done much with 910 funds in an imagina- tive or ingenious way, and the very first thing we think of doing is to hire another administrator, that just doesn't excite me. DR. MARGULIES: We have used the 910 funds to end 5 Ace: Federal Reporters, ne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 52 support several millions of dollars worth of activities, all the emergency medical activities and the health services in the past year and the cancer center in Seattle, where it was 910 funds. It seems to me you are playing around with the question of whether you think this is a good idea or not, because if you knew, there is a proper way to do it. Up to the present time, this has been going on, and it has been hidden from you because it has been supported by taking part of grant funds from the individual programs to provide payment for him, This simply pulls it out in the open and lets you decide whether it is something you would like to see supported or not. | DR. PAHL: Mrs. Mars, I don't believe we have heard from you. 1R 7535 # 6 © Reba 1 XX APlce-TFederal Reporters, Ine. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 53 MRS. MARS: Before we make any decision on the Southeast, I feel that the presentation should be made of the Northeast application, because the stated objectives and reagons are sited in both, and I don't think it is quite fair to thoroughly discuss one without considering the other. DR. PAHL: Would you please proceed to present the Northeast? MRS. MARS: | If I could, I would go ahead and then ‘let the discussion be continued, because whatever decision is made on one certainly sets an example and influences what must be said about the other. Of course, the Southeast does have the 3 and a half years experience in sponsoring this program, as we have already stated, and it certainly has provided some excellent results, and it has allowed them to move more rapidly, cer- tainly on an inter-regional basis, into new areas of interest. | I am well aware of this, because I am from Virginia and Virginia is part of the southeast. Now the proposal that Northeast is presenting is the result of a joint decision which was reached at the September 14th meeting of the North- east Coordinator's group. This group constitutes 15 regions, and they voted unanimously to authorize submission of this 910 appli- cation. The application is submitted on behalf of a group @: 2 Bce- Federal Reporters, Gne. 10 1 13 14 15 16 17 18 19 20 21 22 23 24 25 54 by the Greater Delaware Valley RMP, which has agreed to act as the host region. They wish to employ a full time staff person whose assignment would be to force interregional activities, improve the coordination of similar endeavors, and in communi- cations problems, experiences and opportunities which require interregional attention. I personally can see many advantages in having such a person. Certainly it would facilitate a more rapid exchange of information among all the members of the group about their individual activities as well as about the federal trends and programs, and certainly going to the south- east program, this is what Mr. Youngerman has functioned and done in our own Virginia program. The position would be financed through the | 910 grant from RMP at a salary of $26,000 a year, plus $3,120 in benefits. One secretary would be employed at $7,000 a year with $840 benefits. The office would be placed at the University Science Center, which is the grantee institution of the greater Delaware Valley RMP, The total budget request for 3 years is $217,678. For the first period, $71,329, for the second period, $71,583, and for the third period $74,766. This includes salary, travel, which Dr. Brennan # 6 @-: 3 Pree. Federal Reporlers, ne. 10 Il 12 13 14 15 16 17 18 19 20 21 22 23 24 25 55 brought up, at an average of $10,500 per year. The office space, $2,000 per year, equipment and communications. The equipment, of course, would come, really, in the first year, I think it appears to be a fairly reasonable request, and certainly not excessive. | The Chairman of the Northeast RMP coordinator group, who is also the director of the New Jersey RMP, by name Dr. Alvin Florin,has received letters with varying degrees of enthusiasm supporting and endorsing, from the directors of the 15 RMP's w-ich are Nassau-Suffolk, New Jersey New England, Rochester, Susquehanna Valley, Western Pennsyl- vania, Albany, Central New York, Connecticut, Greater Dela- ware Valley, ~the States Area, Maine and New Jersey. The liaison committee of the coordinators group will hire and supervise and direct the programmatic activities of the representative and in accordance with the objectives established by the group. The coordinator and grantee institutions of the host RMP will be responsible for the administrative supervision of the administrator, so the supervisory controls are well set up. Personally, t would like to see this funded provisionally for two years only, with support guranteed for the third year if it can be shown at the end of that time that there is an outstanding advancement in the northeast region's effectiveness, its’ programs and its impact on the # 6 © Reba 4 Ace- GTederal Reporters, Ine. 10 di 13 14 15 16 17 18 19 20 21 22 23 25 56 problems thereof. I do not feel we can recommend funding for one year. Certainly no individual of the desired quality would be willing to take such a position for only one year. And especially in the light of the high standards that have been established in the job description that they have presented. So I visualize this, really, as an aid in solving problems of regional overlap, geophysical problems, and preventing situations and helping to resolve them, such as we have heard about so much in the last day, as between bi-stat and Illinois. | I think if such an organization and such a group had existed, many of these can be resolved. So that I think it is a tool that can be used to great advantage by the regions, and if we do approve this, of course, we are estab- lishing a prototype which I feel personally can become a very useful thing. So in order to facilitate more discussion, I move we approve the northeast 910 application, but with a recommen- dation that it be done for a two-year period of funding with ep third year of funding guaranteed if after assessment at the end of that time, it appears justified by outstanding program achievement in the region. DR. MARGULIES: I wonder if we could hold our motion For the moment and go back to the previous one, which is still # 6 Reba 5 Arce-Federal Reporters, Gne. 1 10 11 13 14 15 16 17 18 19 20 21 22 | 23 24 25 57 on the table. MR, OGDEN: We have a modest conflict in it, that I have said in the questions I had raised which were answered and were things which we could discuss and have conclusions about, that I would recommend a 3 year funding for southeast with annual reports to the council now on the progress and accomplishments of this. So I would think if we are going to fund Southeast -for 3, we ought to do Northeast for 3 at the same time. Now we have been passing some notes back and forth across the table down here, and we have come to the conclusion if there were about five of these, this could run to about half a million dollars a year throughout the United States. So we are not talking about a significant amount of money. My own reaction to this is that this is a worth- while expenditure. I recognize the fact that this is a new precedent in the use of 910 money, and I would suggest that if we approve this we do it on the understanding that we are going to have one man in an area, a group of regions doing this, and that we don't know begin to have a 910 application for somebody to coordinate kidney and heart disease and stroke and cancer, and a proliferation of activities. 'DR. SCHREINER: These five fellows are going to i # 6 Reba 6 Ace-TFederal Reporlers, ne. — 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 25 58 establish a liaison, and then want an office to coordinate that. | DR, OGDEN: Let's don't start a parade of horrors. That is a legal argument, and I have used it many times. Let's cross that bridge when we get to it. The thing that concerns me at the moment is that we would want to see someone coordinate kidney, or something of this nature, and I would suggest that we settle with the understanding that there is going to be one man involved in this kind of thing. MR. PAHL: Dr. Komaroff? DR. KOMAROFF: You said it is all the same pot of money, but as I see it, although funds are small, you are really saying that some supplemental money, on the order of $3 to $5 thousand per region, should go into the administrative part of the total RMP expenditures. They are now doing this. They are now supporting this man, and this gives a supplement of a small amount, _ about $5,000 per region, for core administrative support, and I wonder whether Mike's point isn't the most telling. I am also bothered by using 910 funds for a non-operational purpose, but this is just another and perhaps very valuable administrative mechanism. If it is that valuable, the regions themselves will demonstrate their faith in its value by using their existing administrative funds to support it, as they have “#6 Reba.-7 Ace-Federal Reporters, Gne. 10 11 12 14 15 16 17 18 19 20 21 22 23 25 59 and --- DR. OGDEN: I don't feel an objection to the use of 910 funds for administrative purposes if it is going to do a real job of coordinating the grant activities in the regions. DR. MARGULIES: Since the funds are now being — utilized out of existing grants, this would merely mean that the same amount of money would be used for this purpose. it ~would not add this amount and leave in their grants what they have been using. | It would be keeping it at the same level. DR. OGDEN: To get us to a point here, and without meaning to cut off further discussion, I am going to move, if it is appropriate, that both Southeast and Northeast then be funded for a 3 year period with annual reports to the Council on the progress. DR. MCPHEDRAN: You mean this won't increase the administrative costs? DR. MARGULIES: Well, it would increase the Northeast, because they are not paying for this kind of individual, but in the southeast they are already paying for it. . MRS. MARS: They are using money which could be . used for programming. DR. MARGULIES: Could we have a second to this? 60 # 6 Reba 8 1 - MRS. MORGAN: I second it. © 2 DR. PAHL: Is there further discussion? 3 Dr. Brennan? 4 DR. BRENNAN: I think that it is important for us 5 to remember that we are probably facing a considerable re- 6 || duction in the availability of funds for RMP activities 7 || generally next year. The 910 funds are our chief hope for 8 || being able to move out promptly into the control activities 9 || which we have been advised we had best learn how to include 10 | here ina stronger way, in Mr. Stone's statement yesterday, 11 | and in other sources. 12 I think that the half million that we can end 13 up getting into this new layer of administrative work, if we 14 look acrass the country, it will run us something on the order Pee Federal Reporters, ue. 15 || of half a million a year. That may be perhaps far better 16 || spent in other ways. C 17 . Furthermore, I think it is the duty of these 18 || coordinators, and a requirement of their job that they communi 19 | cate with their neighbors and that they sustain these pro- 20 | grams, and I honestly don't believe that we have to add this 21 | kind of administrative level. 22 What with all of the means we have, thatis true. 93 || RMP staff isn't as large as it was. But what are we doing? @ 24 || Are we circumventing administrative, an attempt to keep down 25 || the proliferation of administrative activities in these ! # 6 Reba 9 } © 10 11 12 13 14 Ace- Tederal Reporters, ne. 15 16 18 19 20 21 22 23 24 61 programs by going around a directive that says "no more administrative help to be hired" and taking from grant operations for the purpose of an expansion of this kind? DR. PAH: Mrs. Wyckoff? MRS. WYCKOFF: It is very plain to me that coordinators and people from the different RMP's seem to learn a great deal from each other. They enjoy the direct communication over the back fence, comparing notes and how does it work in your area, much more than they do going up- stairs and communicating with a higher level, and I think this thing has some great value in oiling the wheels between the coordinators. 62 CR 7535 #7 1 DR. MARGULIES: I think before you vote on this, © kar 12 you should realize that -- I don't know any way of putting it 3 || without appearing to influence you, and I am trying not to, 4 but if you vote against it, then we will’ have’ to instruct 5 Southeast to discontinue the employment of the individual 6 || who is there, because the principle remains the same. 7 This is money which is being used out of grant 8 || funds to support an activity. | 9 | ~ DR. KOMAROFF : I think there is a difference. 10 DR. MARGULIES! They cannot do it legally the way 11 it is being done at the present time. 12 DR. KOMAROFF : Let me suggest that it may be true 13 that the Southeast group who already has such a person, if you 14 award them the $53,000 in the 901 funds, you deplete each of Prce- Tederal Reporters, Ene. 15 their other awards not made out of 910 funds accordingly. 16 | Tha® threatens not to be the case in the Northeast group and 17 || the potential Western group and the others. If we could be 18 || assured that a group of regions that chose to use this 19 mechanism and to fund it this way would, in a sense, sacrifice 20 their non-910 and core support, it would make me -live easier 21 || with it. Conceptually, it may be a great thing. The Southeas 22 || group has obviously made that judgment. 23 MRS. MARS: We are destroying it if we vote against it. 24 @ 25 DR. KOMAROFF:. ‘I am not suggesting we vote against kar 2) 10 1i 13 14 Brce- Gederal Reporters, Ine. 15 16 17 18 19 20 21 22 23 24 25 63 it, only that we have administrative assurance that it won't become extra administrative money in each region. DR. SCHREINER: I have to disagree with that, Mrs. Mars, because you are flaunting Parkinson's law. We have southern governors' conference and all kinds of people who meet together on an inter-regional basis and elect a president or a vice-president, and this is part of their job. You don't need somebody, if there is a natural desire to band together for a five multi-regional program, you don't need something to tell them that. If they are pros, they are supposed to be doing their job. But they have | authorization and have travel funds. They have authorizations to have meetings. They can bring administrative staff in. I think what you are really doing is, you are going to have them regress, because you are saying "Okay, now, don't do this for yourself, we are going to have another fellow do it for you," and it is not voting against the idea. It is voting against the proliferation of administration which sometimes paralyzes ideas. MRS. MARS: — Someone has to coordinate, though, and be chairman. DR. SCHREINER: That takes an election. MRS. MARS: But the coordinator in the Northeast case who has been made chairman of the group has found that it is just too much of a burden. He is neglecting his other work | | | Pree-TFuderal Reporters, Gre. Sl kar 3 1 np 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 64 in attempting to coordinate work between the regions, and for each of them to be able to understand what is going on in another region. This would be a help to him, just as it has been in the Southeastern group for all of us to benefit from what is going on in the other regions, whereas it is not takin time away from the coordinator who should be spending time in his region. There are only 24 hours in a day, and a man can't travel between 15 regions. None of them can. DR. PAHL: Mr. Merrill had the floor. DR. MERRILL: I just wanted to be sure of one point Am I correct in understanding if we were to vote against funding this particular individual from 910 funds that his position would no longer be tenable because his funding as it is now carried out is illegal? | MRS. MARS: That is correct. - DR.’ MARGULIES: That is correct, and furthermore, the question is really one of the principle of whether funds which are available for grant’ purposes should be used as this discussion has indicated, yea or nay. | DR. PAHL: Dr. Brennan? DR. BRENNAN: I think we are now in a position where if we are talking about a principle, whether or not grant funds should be used in such and such a way, we are clearly talking politics. We are not just talking about two Arce- Federal Reporters, Gre. 10 il 13 14 15 16 7 18 19 20 21 22 23 24 25 65 grant applications, and if that is where we are, we are in th séssion not able to make such policy. DR. MARGULIES: It is impossible, Mike, to disting on a grant application the difference between forming a policy and acting on policy. I think in this particular case you are acting on policy. : 7 DR. BRENNAN: I think the character of this dis-~ cussion shows the group is seeking for: some kind of a policy position, but regardless of that, it is inconceivable to me that these five regional medical programs could not find some way legally to hire this man. | If one of the programs decided to hire him as part of his core staff and, simply assigned him to this duty in the interest of the good of the program, I don't see how we could Say that that was illegal. DR. MARGULIES: Would you approve that? DR. BRENNAN: Why, good Lord -- DR. MARGULIES: What is the point of distinction: between doing that, and the magic you are applying to 910. It is all the same money. DR. BRENNAN: But there is a different control factor.. ; DR. KOMAROFF: That is part of it, and with the Northeast group, this appears to be. $70,000 split up 15 ways to these regions. We are talking about extra administrative x Arce- Gederal Reporters, Ane. kar 5 10 ll 13 14 15 16 17 18 19 20 21 22 23 24 25 66 support, it seems. although with regard to Southeast, there is the assurance that the total: level of the administrative costs won't go up. . Why don't the other regions contract out to Georgia for the services of such a person? | | DR. MARGULIES: You have to quit playing with this, issue. Either you don't believe the issue, or a do, and that is what you are voting on. DR. BRENNAN: You are giving us a false position. We refuse to be put in the position of saying that because we oppose this, we oppose coordination. DR. MARGULIES : You are talking about whether a man should be hired with secretary and supporting staff with grant funds, and inthis case in order to do it, you have to use 910. That is the issue. DR. KOMAROFF: It is extra money, as well as 910. DR. BRENNAN: Harold, would you tell me categorical that it would be illegal for Georgia or someone else to hire the man and pay his salary and assign him to this function? DR. MARGULIES: Yes. That should be covered under 910. — DR. BRENNAN: It would be illegal? DR. MARGULIES: It is improper use of grant funds. If the Council wants to approve the use of funds for that purpose, it will have to go through 910. And if it is going to be done, the Council shovld approve it. kar 6 Avc5e-TFederal Reporters, Ine. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 67 MR. OGDEN: I move the approval of the two pro- posals. | MRS. MARS: I still would like to say that I think that Northeast should not be funded for more than two years with a guarantee of the third year, because it is an experime: Southeast has had three and a half years experience, and they know what they are doing. The Northeast may not be capable o carrying out such a procedure. DR. MARGULIES: Do you accept that change? MR. OGDEN: Three years for Southeast, and two for Northeast. MRS. MARS: With that third year guarantee. MRS. MORGAN: I second it. DR. PAHL: Is the motion clearly understood by the Council? If so -- MR. HIROTO: If we vote against this because the funds are being used not according to guidelines, that the Southeast ‘project is ‘basically illegal, and that Northeast -- DR. MARGULIES: Jerry, do you want to comment on that? 7 MR. GARDELL: I think the use of the term "illegal' is probably one that should be pursued a little more from this point of view. The way the support of our Southeastern coordinato1 ~ is being budgeted is, I think, unacceptable. He is not shown kar 71! Bce- Gederal Reporters, uc. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 68 in any category in any budget. In other words, as Tony is saying here, if you reduce -- if you support him under 910, there is an automatic reduction to the grant. We can't actually go out and find that money at the moment, because ~ none of the regions actually has a budget item for the support for the individually collectively. | So it comes out of what we talked about as a kind of a slush fund in the grants. This is what we don't want to continue, because I am afraid that should an auditor get out there and find there is specific support for an individual of this sort, there is no budget item for it, he is performing service for a number of programs, I don't think we should continue in that vein. I think that is what Dr. Margulies is trying to get across here. DR. BRENNAN: Would your objections be overcome:.if a region agreed to hire this man and other regions prorate on a line item in their RAG approved budgets, monies for this function? What would be wrong with their doing this? : MR. GARDELL: I don't think there would be anything illegal about it, but I don't think we have approached it from that point of view, and before I answer, I would like to pursue it a little bit. We are now developing informational people out in “ the regions who are coordinating the activities, and their Alce-Federal Reporters, ne. 10 11 13 14 15 16 17 18 19 20 [-3} 22 23 24 25 69 activities are being coordinated from here, and I would like to take a look at the whole picture rather than an individua: application like this, or one region supporting it, and obviously we haven't discussed it to that extent around here to raise all the pros and cons, but I think that might be appropriate. - | DR. PAHL: Dr. Merrill? DR. MERRILL: I think we are really touching the basic issue, and the same identical question has been asked four times, reflecting the uncertainty of everybody concernec about whether or nto it is legal or according to guidelines or not, and I am sure that in my own mind I asked the questic first, that if I were sure that it could not be done any othe way, I would then vote for it, but I cannot really imagine some legal way could not be found for doing it. I wonder if there is any possibility that we defer the vote on this until we do get a very clearcut policy statement on it. DR. MARGULIES: Would it help you any to hear the language of the 910 section, which Mr. Baum can read for you? MR. BAUM: The actual language of the legislation reads as follows: "Section 910A. To facilitate inter- regional cooperation and develop improved national capability for delivery of health services, the secretary is authorized to utilize funds appropriated under this title to make grants Plcé-Tederal Roporters, ue. 10 11 12 13 14 15 16 7 18 19 20 21 22 23 24 25 to public or nonprofit agencies or institutions, or combin~ ations thereof, and to contract for (1) programs, services and activities of substantial use to two or more regional medical programs. (2) Development, trial or demonstration of method or control of heart disease, cancer, stroke, kidney disease or other related diseases. (3) The collection and study of epidemiologic data relating to any of; the diseases referred to in paragraph two. | (4) Development of training specifically repre- sented to the prevention, diagnosis, or treatment of any of the diseases referred to in paragraph two, or to the vehabili- tation of persons suffering from any such diseases, and for continuing programs of such training where shortages of trained personnel would otherwise limit application of know- ledge and skills important to the control of any such disease, and (5) The conduct of cooperative clinical field trials. - (B) The secretary is authorized to assist in meeti the costs of special projects or approving development of new means for delivery of health services concerned about the diseases with which this title is concerned. 1C) The secretary :is authorized to support resear 71 kar 10!) studies investigations, training and demonstrations designed © 2 to maximize the utilization of manpower and delivery of health 3 services." 4 ' That is the total thing. 5 DR. PAHL: Thank you. 6 DR. MARGULIES: Are you ready for a vote? 7 MR. OGDEN: Yes. 8 DR. MARGULIES: All those in favor, please raise é " 9 || your hands. og : 10 (Hands raised.) % § 11 DR. MARGULIES: Opposed? S42 . & (Hands raised.) @ g 13 DR. MARGULIES: Let's do that again. ° “3 % 4 All those in favor please raise your hands. S 15 Opposed? 16 It is carried. ( : ~ 7 DR. CANNON: What was the count? 18 DR. MARGULIES: Seven to four. 19 2 Ivam sorry. It was seven to five. 20 ~ : . MR. OGDEN: Do you want to do it again? 21 DR. MARGULIES: Let's do it again. Ten are for it. C 22 | r don't count very well. 23 Opposed? There are five opposed. It is ten to fivi @ 24 We can have a coffee break or go on, whichever 25 you prefer.- — . kar il E #7 Pree- Federal Reporters, Ine. 10 11 i3 14 15 16 17 18 19 20 21 22 23 25 We will adjourn for 15 minutes. (Coffee break taken here.) fz _€R7535 Oi 73 Al #8 To jrb. i . .. J . DR. DE BAKEY: If you will take your seats, please, © 2 4 we will continue. 3 We have one 910 application to review, which should 4! not take long. . This is a kidney application from the 5 || Metropolitan New York Area, and Dr. Hinman is going to 6 || introduce it, and the discussion which follows will complete 7 || the formal action on the 910 applications. XXXXXXXX 8 DR. HINMAN: This represents an application ( . 9 || submitted by the Metropolitan New York Regional Program as a 10 | 910 application covering New York, New Jersey and the 1l | Nassau-Suffolk RMP. Ie It is submitted by the Council of Blood Banks of 13 New York City and the object is to develop a multi-region 14 | organizational procurement network with tissue-typing facili- Arce- Gederal Reporters, Ene. 15 ties. 16 The original application was for five years of “ M7 support with the first three years being level funding and 18 then showing a fourth and fifth year with some third party 19 reimbursement for thé organ procurement and tissue-typing 20 | activities. 7 21 A staff assistance visit was conducted in ( 22 September and the budget that is shown on the yellow sheet 23 || was the one that “was resubmitted after that. @ ad This was reviewed in conformance with the kidney 25 || guidelines by three outside technical reviewers. At the time ~~ jxro 2 Ace-GFederal Reporters, Gne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 74 they were originally there, they expressed their basic endorsement and support of the proposal. Subsequent to that visit, some additional informa- tion has come toa light. The first of these things was: that we received an application from Downstate Medical School for a transplantation and tissue-typing activity; and Downstate Medical School was supposedly one of the active participants in this 910 application. This may have been engendered by the fact that the new Chairman of the Department of Surgery just arrived October 1 at Downstate. The second thing is that last Friday we received a letter from two of the transplant surgeons at Montefiore withdrawing their support of this application. The Staff is left at this moment with an application to do something that is considered extremely worthwhile, but some question as to whether the commitments expressed in the application sent in in June and July are indeed the commitments of the individuals in the region. Staff also still has some question about some of the budgetary items, and I guess I will give it to you. Dr. Merrill is the review now. I will give it to him for conclusions. ~ DR. MERRILL: Well, this is a problem with which I am quite familiar, although the material on it arrived in ~ oN f jxb3 Arce- Federal Reporters, Ine, 10 11 13 14 15 16 17 18 19 20 21 22 23 24 25 75 Boston about the time I landed in Mexico, but I think I can comment on it. ° Really, the problem is simply that if one is going to have a regional typing laboratory for organ sharing, it has to be truly regional, with a participation of, obviously, more than one hospital, or even one big center. The problem, as it is becoming more evident, is that if one is going to set up a program for procuring cadaver organs, the typing as it exists now makes it absolutely neceaaary that it be a large program. Therefore, with that in mind, if Downstate is putting ina separate application and Montefiore has reser- vations about whether they want to participate, it seems to mé that this is not yet in a stage where it can be of real help in a true regional sense. | However, as Dr. Himan indicated, I think it is essential that some kind of tissue-typing activity be kept going, at least until the participants themselves can decide on exactly what they want to do. It may take the new chairman of Downstate a little while to do that. With that in mind, and Dr. Musser has read this -- he and I agree. It is, I think, the feeling of all of us that we cannot recommend approval of the project at the present time, but that we do recommend that considera-: tion of the proposal be deferred pending a staff site visit “ : t _ f N jrb 4 Pree: Federal Reporters, ne. 10 11 12 13 14 15 16 7 18 19 20 21 22 23 24 25 76 to study and evaluate and, hopefully, to reconcile the uncertain aspects of it -- that is, the participation of Montefiore and Downstate. It is possible that the Blood Council Blood Banks may run out of funds for their own endeavor between December 31 and the end of March, and with that in mind, since we. believe some sort of nucleus ought to be kept going on which they can build, I would recommend and Dr. Musser agrees, that the Director of RMP's should be authorized to provide interim funding should he find such to be necessary. DR. PAHL: Thank you, Dr. Merrill. DR. SCHREINER: John, what are we going to do about the Downstate application? DR. HIMAN: The Downstate application has not gone through the mechanism and has not been reviewed by RAG, so it is not really a valid application. It arrived unsolicited, and has not gone through any of the appropriate mechanisms. The 910 mechanism seems ideally suited to try to assist the Metropolitan New York Area in the development of its transplantation activities, and we hope, and we have been in some discussion both at the Transplantation Society and at the Kidney Consultant Meeting with some of the parti- cipants in the total activity in New York City. We think we can hopefully pull everything together to agree upon, one, ~ fo’ jrb 5 APrée-TFederal Reporters, ne. 10 11 12 13 14 15 16 17 18 19 20 al 22 23 24 25 77 a Yeliably neutral area; two, an appropriate technical controlling advisory or policy-making group that is appropriately recommended. This is one of the issues that was raised, to whether there was an appropriate representation on the proposed advisory committee to the council's blood banks; and, three: that this will then, Montefiore will withdraw its letter of withdrawal and go back to its original commitment, and that now that the new chairman of the department is at Downstate physically and starting to talk with people that we can reconcile their concerns. We are optimistic that we may be able to get a single application out of this that will include the three | Major activities, the Cornell, the Downstate and the Einstein activities. ‘ DR. MERRILL: I think if you don't do something like that, knowing the situation in New York, that you are going to have utter chaos, because the problem is one of a very energetic young nian moving into an area which actually has moved rather slowly to date, and it may well be that downstate under these circumstances would be doing all of the transplanting and tissue-typing. I think that is probably not the way we would like to see it go. MS.. SILSBEE: I think it is important for the council to tealize that there are other areas, New Jersey yr jrb 6 Prce- Federal Reporters, Gne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 29 78 and the Nassau-Suffolk. So any word that goes back with regard to this action should be done in a way that would enhance this cooperative effort rather than help to bring it down. DR. SCHREINER: This is the point I was about to make, that anything we can do to support the staff on this kind of a situation, and what I would hope would not happen is that some isolated carrier would be funded in the meanwhile, because it seems to me that there will be a | deterrent to trying to accomplish the larger goals. I think we ought to do anything that we can do to bolster the cooperative effort. DR. DE BAKEY: I think that is the intent, as Dr. Himan has pointed out; and what we will do with this -- not really application, but more a statement of intent at the present time -- is go back and try to bring the people together and have them do this as a regional issue. DR. SCHREINER: So the best thing we should do is turn this, one down? DR. HINMAN: Rather than a straight turn-down, because we want to encourage the regional activity, what we would appreciate would be a motion to the effect that we encourage the activities that have gone on, but because of the question concerning commitment and budget that the council defers action until its February meeting. ~~ f ‘ jxb7 Adce-Federal Reporters, ne. 10 11 12 13 14 15 16 V7 18 19 20 21 22 23 24 29 79 We would like it to be as encouraging as possible, because the problems of Metropolitan New York are overwhelming in many respects, and these tentative steps forward should be encouraged, rather than discouraged. DR. MERRILL: Would you like a formal motion? DR. PAHL: Yes, please. DR. MERRILL: I would like to move that the present applications are deferred, or consideration be deferred pending a staff site visit to study, evaluate, and hopefully to reconcile some of the uncertain aspects of this present application, and also -- if I may include this in the motion -- in the interim, the Director of RMPS should be authorized to provide interim funding, should he fund such necessary. —_ DR, MARGULIES: Is there a second? DR. SCHREINER: Seconded. DR. PAHL: The ‘motion has been made and seconded. Is there further discussion? All in favor of the motion, please say "aye". (Chorus of "ayes.") DR. PAHL: Opposed? (No response.) DR. PAHL: The motion is carried. Before we turn to the concluding business of the meeting, let me indicate that immediately after this om oN Ace- Gederal Reporters, ne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 80 meeting, Mrs. Mars has stated she will be driving to the Dulles Airport and can accommodate passengers, if you will see her, In the back of your book, under the blue tab, there are four regions, California, Colorado, Wyoming, Georgia and Maine, with some information -- for your information only. No council action is required. If there are questions from members of the council about these materials, the staff will be glad to respond. If there are not questions, perhaps we could go on to a discussion of the statement presented yesterday by Dr. Stone yesterday, which I understand several members of the council would like to discuss. DR. DE BAKEY: Mr. Ogden? MR. OGDEN: Ladies and gentlemen, I think yester- day this council received a very important statement presented by Dr. Stone which, at that time, received very little comment on it other than some questioning to him about a few parti- culars of the statement. But I think thathis remarks mve concerned some of us, that it may portend changes in policy directions. Perhaps it is a statement made to open the options depending upon funding for RMP and the control programs to which it refers. Yet, because it will be in the minutes, I suspect that it will cause concern among our coordinators &, jxrb9 Arce-Federal Reporters, Fane. 10 11 12 13 14 15 16 17 18 19 20 ai 22 23 24 25 81 and our RAG's who may see in it a further shift in emphasis and activity. As I see it, if RMP money is to be used for control programs; this means a vast reduction in our currently-committed funds, and a definite change in what we have been planning to do. I cannot believe that such a change would represent revenue sharing at its best, which is a term used in the state If control funds are awarded to the institutes referred to and administered through RMP as supplements to our activity, then that is perhaps another matter. Also, pr. Cannon raised a few moments ago a questic concerning a statement made that referred to regional medical programs as being limited to states or subregions to states. Inasmuch as I am Chairman of the Interadvisory Group of Washington-Alaska Regional Medical Program, I am concerned that perhaps a statement has been made here which is historically not accurate, and is counter to > policy which this body has established. I have a feeling that this statement needs review in depth by this council, There is no doubt that none of us have a chance or have had a chance to do it within the last 24 hours since we received it. I think we will want to have reaction from our coordinators, and from our director and CY {rb 10 Arze-Gederal Reporters, One. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 82 from the staff. I am going to suggest that many others here may ha comments if they wish to make them, but I am going to suggest that after the budget becomes known, perhaps this should be a special meeting of council to consider the course to follow and to deal with the issues raised in Dr. Stone's presentation These will have to do with substnatial policy matters before this council, and also with the policy which we have established on the duration of the funding and the phasing out of projects, which also is touched on. Now, since policy apparently can no longer be made in closed meetings, as I understand it, it would a be proper for us to make policy at this particular session; bu I raise these things as a matter of concern, as a matter of direction for the program, in the hope that it will” encourage all of us to dwell on this with the gravity with whi I think it deserves. DR. MARGULIES: Thank you. Mr. Ogden. The statemen is open for general discussion. I would like to respond by saying that I think that is a highly appropriate idea. To consider any policy ina. vacuum is difficult. The implications become clearer as we know what the funding will be. The statement emphasized the relationship between the National Cancer Institute and Heart and Lunch and Mental Health, and the regional medical jxb 11 Asce- Federal Reporters, ne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 83 programs, and there were some necessarily speculative concepts there, because we don't know what the funding will be. It does make a difference whether you are talking about one level or another. It makes a great difference when you have to look at a policy and realize, as Mr. Ogden has said, that it presents an option and the options become much sharper when you know exactly how much money is available and what the position of the coordinators and the other groups may be on it. So that I would be perfectly happy to carry the message of another meeting of the council, preferably, I am sure, with Dr. Wilson available to discuss the policy impli- cations, and certainly at a point where we know the budget. I think prior to that time it becomes extremely difficult to know what the - policy means in terms of actual RMP functions. We will plan to do that. I would like to say one other thing while the opportunity is here: | And unfortunately some of the members to whom it would be addressed are not available, but it is a reasonable time, excepting that they aren't here, to again call attention to the fact that two members of the council have served the maximum period of time they canbe on the National Advisory Council, Dr. Clark Millikan, and Dr. De Bakey. It is jxb12 Jee. Federal Reporters, GFne. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 84 difficult to think of regional medical programs without them, and the name of DeBakey has been associated with RMP since the beginning. I pay respect to the Chair, which is vacant, but which has often been filled, and effectively, and Clark Millikan's, which is virtually always filled. o. He was called away for reasons beyond his control. We never know what happens with members who have completed a term and are available for others. If I say anything nice, they may be back here, and I may have to rectify what I said while you were here. MS. WYCOFF: Except I think I can act in the voice of the council in saying we deeply appreciate what these members have added to the whole history of RMP, and the deliberations of this council. MR. MILLIKEN: I am asking impossible questions, I guess, but some of us face within the next month or the month ina half -- would it be possible to get any further clarification of this new proposed policy that would be helpful or at least give us not more than five directions to go at once? DR. MARGULIES: That is a very good question. Are there other items of business? (Laughter. ) DR. PAHL: If not, before we adjourn, I would like to thank the members of the coyncil, and our staff, #8 Dee- Federal Reporters, One. jrb13 ro 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 particularly Mrs. Handell and Katie Stevers, for making the arrangements and keeping this running smoothly. With that, we stand adjourned. (Whereupon, at 11:25 a.m., 17 October 1972, the hearing was adjourned.) se 85