Health Planning in the United States Selected Policy Issues, Report of a Study, Volume I (1981) / Chapter Skim
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II. Selected Issues in Health Planning
II. Selected Issues in Health Planning
Pages 5-30
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From page 5... ...
In general, the health planning program in the United States may be characterized as a citizen-dominated trusteeship in the field of health. At its best and at its most inspiring theoretical level, it may be seen as a new institution charged with helping to ensure that individual institutions or actors will promote, or at least not adversely affect, the development of a health care system that provides for all the citizenry "access to quality health care at reasonable cost."*
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From page 6... ...
The planning program was not intended to be a major cost containment device and it lacks the authority needed to control expenditures. But with the likelihood of a national health insurance program fading and little promise of a cost containment bill making it through the Congress in the late 1970s, the cost containment potential of the health planning structure received increasing emphasis by its federal administrators.
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From page 7... ...
In the structure of the health planning system, the only intersection of planning responsibilities with financial liability is in state governors' offices. State Medicaid expenditures are among the fastest growing and most politically sensitive of all state budgetary items, yet the health planning program, at both state and federal levels, has never fully recognized this possible convergence of interests.
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From page 8... ...
The committee is not suggesting that process considerations form the sole basis for program evaluation. The priorities for the planning program set forth in the enabling legislation suggest that Congress had definite ideas about the outcomes of the process.
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From page 9... ...
Existing areawide and state comprehensive health planning agencies were judged lacking in ability to implement their plans. Resource development programs, such as the Regional Medical Programs, the Experimental Health Services Delivery Systems, and the Hill-Burton facilities construction activities, were seen as excessively fragmented and isolated from community planning efforts.
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From page 10... ...
The remainder of the members of the governing body are to represent health professions, health care institutions, insurers, educational programs for the health professions, allied health professions, and hospital administration. The membership of the governing body must also include, through its provider or consumer components, representation of general purpose local government, elected officials, non-metropolitan areas, and mental health interests.
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From page 11... ...
The agencies collect and analyze data concerning the health status of the area's residents and the health resources available to them. With this description of existing conditions, the HSA develops goals for the following five years, describing a desired state of community health and health services.
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From page 12... ...
But there was little interest in its removal in 1979 and appropriateness reviews of selected services are now underway. Proposed Use of Federal Funds Another congressional concern during the development of the basic health planning legislation was the consistency of federal health proects and contracts with local goals and desires, as well as existing services.
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From page 13... ...
Certificate of Need and 1122 Review -- HSA One of the major implementation tools given planning agencies is the review of proposed institutional capital spending. The HSA recommends to the state agency approval or disapproval of applications for capital expenditures.
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From page 14... ...
Congress assumed that prior review and authorization of capital expenditures would help prevent duplication of services and facilities, which, in turn, is supposed to hold down inflation in the health industry. In addition, certificate of need was seen as an instrument for regionalizing the health system and giving power over resource distribution to community and state health planning activities.
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From page 15... ...
In a new Title XVI, the Hill-Burton program was replaced by a more modest effort focused on modernization of medical facilities, construction of new outpatient or ambulatory facilities, and conversion of existing medical facilities to permit the provision of new types of health services. The 1979 Amendments added authority for federal grants to assist institutions in discontinuing unneeded services and converting unneeded facilities to other uses but no money has yet been appropriated.
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From page 16... ...
Program Funding Funds for the planning program have always been modest. The total amount of money appropriated for all of the federally-sponsored health planning and regulatory activities under Title XV was $174.5 million in FY 1980.
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From page 17... ...
Internal Stresses in the Planning Program The restructuring of the planning program has created tensions in inter-governmental relations and relations between the public and private sectors in the health care field. The Act's insistence on an expanded consumer role in the planning process also has created problems as traditional power relationships in the health industry are threatened.
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From page 18... ...
O There is little recognition of the concept of affordability, yet planners are tied by statute and the courts, to a tradition of determining ''need."* o Planning agencies deal with problems that are poorly understood by the public and not well understood by public officials and professionals.
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From page 19... ...
o There is an impatience with programs of this sort in this country. It is not clear whether the Congress and the planning program's supporting coalition will recognize the importance of institutional maturity and long range capacity building and allow the program time to achieve anything worthwhile.*
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From page 20... ...
Despite the wide range of topics encompassed in the priority list, such as medical care organization, professional training, improved management of health enterprises, community health education, and health promotion, the subsequent action of the Congress and the Administration have made it clear that the expectation is for cost containment in the institutional sector. Cost containment has become the goal against which some members of Congress and the executive branch judge the effectiveness of the program, despite the limited abilities provided to planning agencies for controlling expenditures of health providers.
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From page 21... ...
Each goal has value and it is the very fact that the choices are hard, touching highly personal elements in our lives and involving deeply held values that make a process like planning so important. Clarity about those conflicts and acceptance of the process must be recognized Connected to the need for well-defined goals is the need for a reasonable set of expectations for the health planning program.
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From page 22... ...
Lessons learned about shifting the balance of power in medical care, establishing more effective means for allocating resources in the health sector, and making the health system more accountable to the public will find increasing application as federal investment increases in financing of health services. It is important to note that clarifying the objectives of the planning program may have some negative as well as positive effects.
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From page 23... ...
To establish and maintain an open 9 participatory structure for articulating community health needs and desirable alternatives for meeting those needs, to be used in advising both ~ _ governmental and private sector decisionmakers who control health resources at the local, state and national levels; To contribute to the redirection of the health system, through planning for a more effective, accessible, higher quality and more efficient configuration of facilities and services, that is more closely matched to basic health care needs of the area'population. This should include developing a carefully thought out position for dealing with the introduction of new technological advances into the health care system, with sensitive consideration and fair-minded appraisal of all important factors, not only costs.
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From page 24... ...
For example, a long history of voluntary health planning in Rochester, New York promoted rapid development of health systems planning because the community could understand what the work of the new agency meant. Until the planning program reaches a level of maturity, an evaluation can only count intermediate steps toward something.
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From page 25... ...
* Standards issued to date cover acute care beds' computed tomographic scanners, obstetrical services, neonatal special care units, pediatric inpatient services, open heart surgery, cardiac catheterization, radiation therapy, end stage renal disease.
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From page 26... ...
To establish and maintain an open, participatory structure for articulating community health needs and desirable alternatives for meeting those needs, to be used in advising both governmental and private sector decisionmakers who control health resources at the local, state and national levels; The establishment of the health planning forum and the proper composition of the governing body -- at least in terms of structure and sociodemographic characteristics -- can be measured in reported statistics. Although such descriptive characteristics are useful in ascertaining whether or not the program's requirements for ensuring broad representation are being met, they do not ensure that the forum is a good or effective one for the community.
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From page 27... ...
if the HSA governing body reflects a good mixture and balance of the principal actors in the health system, (2) if the HSA receives dollar or in-kind services support from local government or the private sector.
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From page 28... ...
One of the primary purposes of the health planning program, as currently structured, is to control the rate of increase in health care expenditures through modifying capital investment. Not only is there a desire for an overall decline in the rate of increase in expenditures, but there is also an interest in a shift in capital investments to other activities, such as preventive services and those that promote health (e.g., smoking cessation, hypertension and weight control clinics)
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From page 29... ...
The health planning program cannot accomplish all that political rhetoric has demanded of it. The critical questions, however, are what can it reasonably be expected to accomplish?
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From page 30... ...
Regulation, as well as planning, should be open, conducted with due process, and visibly fair. With local participation and with focus on the concrete health care problems of communities and populations, there may develop a substantial willingness to adopt the recommendations of HSAs and to abide by the results.
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