iiii iiii
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                                                                                                                          I .                                        i ,  i-I











                                                            Public  Law  93-641,  "The  National  Health   Planning   and   Resources   De-
                                                     velopment Act of 1974," is to  be  fully  implemented  by  the  U.S.  Department  of
                                                     Health, Education and  Welfare  (HEW)  within  18  months  after  January  4,  1975.
                                                     Essentially the Law does away with  the  nation's  existing  Regional  Medical  Pro-
                                                     grams,  Comprehensive  Health  Planning  Agencies,  Hill-Burton  Agencies  and   Ex-
                                                     perimental Health  Service  Delivery  Systems.  Replacing  these  national  programs
                                                     and discharging their responsibilities as well as new functions will  be  a  network
                                                     of  approximately  200  Health  Systems  Agencies  (HSAS)  within  the  50   States,
                                                     Puerto Rico and the U.S. mandated territories in the Pacific. Each'State  will  have
                                                     a state Health  Coordinating  Council  and  an  Advisory  Council  with  a  consumer
                                                     majority, and each of the States' HSAs will operate  under  a  Governing  Body  with
                                                     a consumer majority.  The  Secretary  of  HEW  is  named  as  the  federal  official
                                                     responsible for administering the Law, and he in turn will be subject to a  National
                                                     Advisory Council with a consumer majority.




                                                                                       Participants

          The Honorable George Elusbee                                     A.    R.    Jablonowski                                  Earl Wright
          Governor of Georgia                                              Assistant Executive Director                             Director o' Health Facilities and Planning
                                                                           Med   ca    Malpractice                                  DHEW Reg@on V
          The Honorable Daniel J. Flood,         M.C.                      Med cal Association of Georgia
          Wash ngton                                                                                                                Robert T. Jones
                                                                           W.    Daniel     Barker                                  Executive Director
          The Honorable James F Hastings, M.C.                             Board Member                                             New  Crleans  Area  Healtri  Planning  Counc   I
          Washington                                                       American Hospital Association                            Gordon R. Engebretson, Ph.D.
          The Honorable Ted Stevens                                        George Pickett, M.D.                                     D rector
          United States Senate                                             Execut ve Board Member                                   Florida RMP
          Washington                                                       American Public Health Associat on                       George      Rosemond,       M.D.
          Henry E. Simmons, M.D.                                           Karen 1. Shanor, Ph.D.                                   President
          Deputy Assistant Secretary for Health                            National Center for Cornmun ty Action                    American Cancer Soc@ety
          DHEW, Washington                                                 Edward Mearns, J.D.                                      Elliot Rapaport, M.D.
          Paul D. Ward, Executive Director                                 Professor of Law                                         President
          Californ a RMP                                                   Case Western Reserve Univers ty                          American   Heart   Assoc   ation
          Walter Branch, Ph.D.                                             Richard Shoemaker                                        Joseph   B.    Stocklen,    M.D.
          Assistant Director for                                           Assistant Director                                       Pres   dent
          lntergovernmenta Relation,@;                                     AFL-CIO Department of Socia Secur ty                     Amer   can   Lung    Association
          DHEW Reg on IV                                                   Daniel 1. Zwick                                          Colon  R.   Wilson   Jr.,   M.D.
          Eugene Fowinkle, M.D.                                            Associate Administrator for Planning                     Nationa Art@ir  tis  Foundat  on
          President-Elect                                                  Evaluation and Leg station
          Associat on of State and                                         DHEW,        Washington                                  James C. Hunt, M.D.
          Territorial Health Officers                                                                                               Pres   dent
                                                                           Gerald    T.    Gardell                                  Nat  ona  K  dney   Foundat   on
          Michael K. Gemell                                                Act ng D rector
          Nationa Assoc ation    of Counties                               Division  of   Regional Medical Programs



                                                                               The  National  Association  of  Regional  Medical  Programs,  2929  Main  St.  Buffalo,  N.Y.   14214











     Foreword             On the last day of the  second  session  of  the  93rd  Congress  the  Health  Planning  and  Re-
                     sources Development Act of 1974  was  passed  in  the  waning  hours.  The  late  December  recess  in
                     governmental functions followed immediately. Perhaps this is why so  little  publicity  was  given  to
                     the  new  Public  Law  93-641  from  Congressional  Offices,  from  the  White  House,  or  from   the
                     Department of Health, Education and Welfare.

                          It became obvious during the  first  quarter  of  1975  that  there  was  a  widespread  lack  of
                     knowledge,  familiarity,  or  understanding  of  the  sweeping  new  health  services  law  among  the
                     many health  service  leaders  and  administrators  who  normally  should  have  been  the  most  con-
                     cerned with its implications for the future delivery of health services and with the requirements  for
                     implementation of the statute.


                          In March it was announced  that  the  Health  Resources  Administration  was  planning  a  series
                     of multi-state informational conferences during  the  month  of  April.  No  similar  plans  were  an-
                     nounced for other governmental agencies or public organizations.

                          Perceiving the urgent need for  early  dissemination  of  pertinent  information  about  the  new
                     law, the  Program  Committee  of  the  National  Association  of  Regional  Medical  Programs  decided
                     on very short notice  to  change  the  program  for  its  spring  educational  meeting  to  develop  a


















      National Conference for Health Service Leaders and to devote the  entire  session  to  a  detailed
      examination of the Health Planning and Resources Development  Act  of  1974  and  potential  prob-
      lems in its implementation. The meeting was designed to be open to the public with all  interested
      leaders and officials in voluntary health agencies invited to attend. Despite a  severely  limited
      length of time for national advertising, 350 registrants attended the meeting.

          The Program Committee is most sincerely grateful  to  the  program  participants  and  to  the
      various agencies that sponsored and  supported  their  appearance.  There  was  a  remarkable  and
      uniform spirit of cooperation among all those involved. Several of the speakers, especially  those
      from the Congress, accepted personal inconveniences in order to  contribute  to  our  enlighten  -
      ment. All of us are indebted to them for their compelling sense of public responsibility.









                                                                     JAMES    W.    CULBERTSON,     M.D.
                                                                      Chairman,    Program     Committee





















                                                   Health  Service  leaders  from  across  the   Nation   gathered   in
                                               Atlanta in late Spring to weigh the implications of a new law  that  may
                                               have more  profound  effects  on  the  health  of  Americans  than  any-
                                               thing seen in a decade.
                                                   It was the first national meeting  on  the  subject  of  the  Health
                                               Planning  and  Resources   Development   Act   of   1974   (Public   Law
                                               93-641) since the law was signed by President Ford in January.
                                                   Richly   varied   concerns,   praise   and    skepticism    threaded
                                               through the  talks  given  by  Congressional  and  Administration  lead-
                                               ers, health care providers, planners,  governmental  officials,  profes-
                                               sional and voluntary health agency leaders and consumers.
                                                   The Atlanta meeting, said John  R.  F.  Ingall,  M.D.,  Chairman  of
                                               the  National  Association  of  Regional  Medical  Programs,  would  ex-
                                               plore all aspects of the law with the  "fundamental  objective  to  make
                                               this law work."
                                                   "The number one  thing  we're  interested  in  in  the  Congress  of
                                               the United States, as I'm sure  you  are,"  said  Congressman  James  L.
                                               Hastings (Rep.,  N.Y.)  of  the  House  Subcommittee  on  Public  Health
                                               and Environment and a  co-sponsor  of  the  bill,  "is  the  development
                                               of some sort of a rational national health policy, something this  coun-
                                               try in my judgment totally lacks."







                                                                                                                    One




                                                         A  succinct  assessment  of  the  new  law   from   Georgia's   Governor
                                                    George  Busbee  set  the  tone  for  the  meeting  called  by  the   National
                                                    Association of Regional Medical Programs:
            The Law's Import                             "I  don't  know  of  any  act  passed  by  Congress  since   1965   that
                                                    will  have  more  impact  on  health  in  this  country,"  he  said.   Others
                                                    agreed.
                                                         Hastings urged the  delegates  "to  devote  the  best  of  your  ability
                                                    to try to make this what I  think  it  really  is-probably  the  most  impor-
                                                    tant piece of health legislation that hit the  floor  of  the  Congress,  and
                                                    most people don't know it."
                                                         The  law,  said  Senator  Ted  Stevens  (Rep.,  Alaska)  of  the  Senate
                                                    Subcommittee   on   Labor   and   Health,   Education   and   Welfare,    "is
                                                    conceived  as  a  preparatory   measure   to   national   health   insurance,
                                                    and  establishes  an  elaborate  system  of  federal  standards   and   regu-
                                                    lations  covering  the  state  and  local  health   planning   agencies   and
                                                    endowing  them  with  strong  power  to  ensure   that   institutions   abide
                                                    by the planning decisions on the delivery of services."
                                                         "While it is too early to tell  how  93-641  is  going  to  work,"  said
                                                    Daniel  J.  Flood,  (Dem.,  PA)  Chairman   of   the   House   Appropriations
                                                    Subcommittee  on  Labor-Health,   Education   and   Welfare,   "it   is   not
                                                    too early to  say  that  we  must  preserve  what  good  relationships  exist
                                                    in the health community now."
                                                         An   administration   view   came   from   Henry   E.   Simmons,   M.D.,
                                                    Deputy  Assistant  Secretary  for  Health  and  Director  of  the  Office  of
                                                    Professional Standards Review.
                                                         "We  now  understand,  I   think,   that   something   more   than   the
                                                    fragmented,  unemployed  efforts  of  the  past  will  be  required  if  this
                                                    country is to secure a right to quality health care for  all  citizens  at  a
                                                    price that society can afford."
                                                         American   Heart   Association   President   Elliot   Rapaport,    M.D.,
                                                    Chief  of  Cardiology   at   San   Francisco   General   Hospital,   declared
                                                    that the  AHA  "considers  that  Public  Law  93-641  has  the  potential  of
            "The aim really is to avoid             profoundly  affecting  the  fate  of  quality  health  care  throughout   the
            waste and duplication. "                country."
                                    - Stevens            And   from   American   Hospital   Association   Trustee    W.    Daniel
                                                    Barker came this  view:  "Although  it  is  not  the  only  way  to  approach
                                                    planning, it is the law of the land at this  time  and  we  have  to  rededi-
                                                    cate our efforts to  make  sure  that  it  works,  that  it  brings  together
                                                    some pretty difficult functions of the regulator,  of  the  planner,  of  the
                                                    provider, all in one agency. This,  in  itself,  is  a  tremendous  Herculean
                                                    task.






            Two





















               A highly condensed review of the major priorities in  P.L.  93-641
          was offered by George Pickett, M.D.,  Director  of  Public  Health  and
          Welfare  for  California's  San  Mateo  County  and   Executive   Board
          Member of the American Public Health Association.
               These priorities include 1) making primary  care  services  avail-
          able  to  underserved  populations;  2)  development  of  comprehensive
          health systems to include sharing among  institutions  and  facilities,
          formation of group  medical  practice  as  parts  of  the  systems  and
          consolidation of high cost, low-volume services; 3)  training  and  use
          of more physician assistants; 4) improved  quality  of  care;  5)  com-
          parison  and  containment  of  health  care  costs,  and  6)  more  em-
          phasis on disease and  cost  prevention  through  nutritional  and  en-
          vironmental  programs  and  better  education  of  consumers   concern-
          ing the appropriate use of available health services.
               "There are a number  of  potential  value  conflicts  inherent  in
          these priorities," Pickett said. "On the whole they point  clearly  to-
          wards the need for a total governmental control of  the  health  indus-
          try in the United States. Those goals, if priorities do reflect  goals,
          cannot, I think otherwise be  achieved.  That  may  not  be  what  Con-
          gressmen voted for and it may not be widely popular.  In  fact,  impor-
          tant goals are rarely  achieved  without  offending  someone's  values,
          but the basic  American  ambivalence  towards  health  and  welfare  is
          moving painfully towards some conclusion."







                                                                                                                Five
















                Although feeling the need  to  get  on  with  implementation,  many
           speakers voiced concerns  with  the  new  law  and  with  the  potential
           for problems in developing  Health  Systems  Agencies  on  local  levels
           and  State  Health  Planning  and   Development   Agencies   and   State
           Health Coordinating Councils on the higher level.
                Boundary  designation-establishing   the   geographic   areas   for
           the  developing  HSAs-drew  much  comment.   The   law   requires   that
           HSA areas conform as nearly  as  possible  to  several  existing  bound-
           aries.
                "I have been through one  session  in  the  Professional  Standards
           Review  Organization  Program  in  which  we  had  to  divide   up   the
           United States. Let me tell you  something:  it  can't  be  done  without
           being crucified in the process.  There  is  no  way  to  satisfy  every-
           body's desire to divide up this country," said Simmons.
                "Geographic  and  population   boundaries   may   be   considerably
           different from those in current use  in  health  Programs.  State  lines
           may  be  crossed  and  interstate  Standard   Metropolitan   Statistical
           Areas will be involved," said  Walter  Branch,  Ph.D.,  DHEW  Region  IV
           Assistant Director for Intergovernmental Relations.
                "Trying to line up the functional regions of the health care  field
           with geographical regions is a difficult if not an impossible  thing  to
           do. We have hundreds of 'regions' in the  health  care  industry,"  said
           Daniel 1. Zwick,  Associate  HEW  Administrator  for  Planning,  Evalua-
           tion and Legislation.






           Six








                                                       Simmons listed the  area  designation  process  as  the  first  poten-
                                                  tial pitfall in implementing  the  law-"How  well  we  carry  that  on  and
                                                  how intelligently we can  meld  those  areas  into  area  designations  for
                                                  other programs the government  has  to  have.  If  that  should  be  fouled
            Concerns                              up it would be  terrible  because  that  would  make  integration  so  much
                                                  more difficult and integration is necessary across the Nation."
                                                       Simmons listed  as  other  pitfalls  to  be  avoided  the  possibility
                                                  that  some  particular  interest  group  could  capture  the   process   of
                                                  building  effective   HSAs   and   health   programs,   weakened   consumer
                                                  partnerships  because  of  inadequate  public  involvement,  and  lack   of
                                                  adequate  and  pertinent  data  required  to  make  the   tough   decisions
                                                  about  costs  and  services  so  that  "everybody  in  fact   doesn't   get
                                                  everything they want."
                                                       Hastings  had  additional  concerns,  as  did  James  C.  Hunt,  M.D.,
                                                  President  of  the  National  Kidney  Foundation  and   Chairman   of   the
                                                  Department of Medicine at Mayo Medical School.
                                                       "A lot of my medical friends differ with me on this, but I think  it's
                                                  disastrous  what  we're  doing  in  the  Federal  allocation   of   Federal
                                                  resources  as  they  relate  to   manpower,   because   in   the   Manpower
                                                  Act we  seemingly  are  just  going  to  try  to  put  more  money  into  a
                                                  system  that  has  not  solved  the  problem-that  primary   problem   that
                                                  I'm   concerned   about-of   maldistribution,   both   geographically   and
                                                  in the specialties. We're  not  addressing  that  question  effectively  at
                                                  all," Hastings said.
            "'The problem I had was                    Said  Hunt:  "The  thing  I  guess  that   concerns   me   more   than
                                                  .anything else is that there is no provision  for  health  manpower  train-
            with the scrapping of                 ing in this legislation. And we are going to build a  system  in  terms  of
            everything that had just              planning and  resources  without  training  of  health  manpower?  That  is
            begun to work."                       impossible."
                                -Stevens               Still other concerns were voiced.
                                                       "The states should  make  a  strong  commitment  in  terms  of  polit-
                                                  ical attention, manpower  allocation,  appropriation  of  dollars,  organi-
                                                  zational prominence  and  so  forth,  to  assure  that  the  law  from  the
                                                  State's  perspective  works  and  works  well,"   said   Eugene   W.   Fow-
                                                  inkle,  M.D.,  Tennessee  Health  Commissioner   and   President-elect   of
                                                  the Association of State and Territorial Health Officers.







            Eight





                 The  State  Health  Planning  and  Development  Agency,   he   said,
             should  be  an  already  established  agency  with  strong  demonstrated
             administrative and other skills; the  State  Health  Coordinating  Coun-
             cil should have highly committed individuals;  enabling  state  legisla-
             tion is needed.
                 Hunt  noted  that  consumers   and   providers   who   have   worked
             together well  in  voluntary  health  agencies  "are  now  being  pitted
             against one another in the new legislation, or at least the  possibility
             of that battle for domination of  the  governing  bodies  of  HSAs  cer-
             tainly exists, so we are going to have to walk a tight  rope  there  ...
             There  are  going  to  have  to  be  a   number   of   compromises   and
             trade-offs between the private sector and government."
                 Without  strong  early  involvement  of   voluntary   organizations,
             said  George  Rosemond,  M.D.,  President   of   the   American   Cancer
             Society,  "no  government  sponsored  or   supported   health   planning
             program is going to reach its  potential.  Our  political  system  seems
             to  require  a  strong  committed  private  constituency  to  make  gov-
             ernment programs  in  professional  and  public  health  education  meet
             their objective."
                 "Regional  Medical  Programs  will  be  gone  soon,"   said   Flood.
             We're not going to sit down and bawl  about  it.  I  am  convinced  that
             no  greater  cadre  of  health  systems  development  professionals  ex-
             ists than the one right here in this room.  Rather  than  cry,  you  are
             going to do something constructive, If I know  you.  You  are  going  to
             do your best to make Public Law 93-641 work."




                                                   ""it is going to be a rather
                                               startling revelation  when  we
                                                discover that  the  machinery
                                       for  improvement   and   development
                                              has  been  dismantled."   -Ward
















                                                                                                          Transition
                                                      The transitional period from the old  laws  to  the  single  new  one,
                                                 said Stevens, "is really the problem area as I see it. I think there is  no
                                                 question  about  the  necessity  to  establish  the  new  program  as  it's
                                                 outlined  in  the  Act  eventually.  The  problem  I  had  was   with   the
                                                 scrapping of everything that  had  just  begun  to  work,  in  my  opinion,
                                                 and  turning  to  a  new  concept  which  requires  the  implementation  of
                                                 a total program . .. and in the meantime to attempt to  phase  out  all  of
                                                 these existing programs."
                                                     "We  must  remain  about  the  business  of  RMPs  in  order  to   pro-
                                                 vide continuity  during  the  so-called  transition  period,"  said  Gordon
                                                 R.  Engebretson,  Ph.D.,  Director  of   the   Florida   Regional   Medical
                                                 Program.  "Just   because   a   new   piece   of   legislation   has   been
                                                 enacted  today  the  health  problems  of  yesterday   do   not   disappear
                                                 only  to  await  re-discovery  and  application   of   the   resources   of
                                                 tomorrow's  newly-created   agencies."   He   suggested   that   RMPs   or-
                                                 ganize seminars  to  help  in  the  development  of  HSA  staff  and  board
                                                 capabilities, and use  their  established  public  information  network  to
                                                 develop  effective  public  education  programs.   He   also   urged   that



         Ten







              Comprehensive   Health   Planning   (b)   agencies   be   assured   neces-
              sary interim support  to  allow  them  to  continue  health  planning  ac-
              tivities. "RMPS, like CHPS, are  storehouses  of  information,  data,  re-
              ports,  recommendations,  findings,  plans  and  so   on.   These   should
              not  become  lost  to  the  planners  and  resource  developers   of   the
              future," said Engebretson.
                   "We really want to make  this  program  work,"  said  Paul  D.  Ward,
              Executive Director of the California  Regional  Medical  Program.  "It  is
              the law of the land; it is going to  need  amendments,  but  I  hope  that
              we  advance  amendments  and   changes   on   the   basis   of   improving
              the situation ... I don't believe that any of us want  to  see  a  further
              deterioration of the health field. I think, too, that we've got to  convey
              our hope for an orderly uninterrupted transition."
                   "This law will not work by itself," said  Stevens.  "Its  success  or
              failure will rest on those people administering and implementing it    ' "
              He urged the delegates to "help  meet  the  objectives  of  the  new  law,
              in spite of  my  questioning  of  it.  Then,  perhaps,  the  Congressional
              oversight  committees  will  be  able  to  conclude   that   the   medical
              needs of  all  our  citizens  are  being  met  in  a  most  effective  and
              efficient manner,  and  we  will  stop  this  biennial  amendment,  change
              and consolidation of national legislation in  the  health  field  and  let
              some  continuity  seep  into  the  planning  and  the   program   of   our
              health care  delivery  systems.  I  don't  think  that's  an  unattainable
              goal, but I do think it will take everyone working  together  to  make  it
              achievable. I would hope that all of you will be  prepared  to  critically
              appraise the  efforts  that  can  be  made  under  this  new  law  and  to
              advise  us  what  changes  you  feel  are  necessary   to   achieve   this
              goal."
                   "If there is danger that the transition period will run  much  longer
              than  93-641  contemplates,"  said  Flood,   "then   the   Congress   will
              surely be pressed  for  some  legislative  relief  ...  It  would  be  bad
              judgment,  unmitigated  stupidity  to  stop  health   resources   develop-
              ment in this country just  because  our  administrative  restructuring  is
              moving slowly."








                                                                                                                      Eleven















                                                   Accompanying  the  concerns  about  the  transition   period   were
                                              equally serious comments about funding support.
                                                   "Everybody has this idea that there's a windfall  of  money,"  said
                                              Earl Wright, DHEW Region IV Director  of  Health  Facilities  and  Plan-
                                              ning. "But if we conceive of full coverage of our  50  states  with  the
                                              HSAs and everybody  gets  50  cents  per  capita,  you  can  easily  see
                                              that $60 million doesn't stretch where 1 05 or 1 1 0 is needed.  One  of
                                              our  problems  might  be  some  retrenchment  in  certain  areas  unless
                                              more funds are made available."
                                                   "We could well end up with less  funding  under  the  new  leg@sla-
                                              tion than we have now," said Robert  T.  Jones,  Executive  Director  of
                                              the  New  Orleans  Area  Health  Planning  Council.  "And  perhaps,  al-
                                              though I sincerely hope not, we  may  see  repeated  the  inequities  in
                                              the funding of CHP over the past few years."
                                                   Stevens reminded the conferees  that  six  years  ago  the  Defense
                                              Department  share  of  the  budget  was  48%  and  that  of  DHEW   28%:
                                              these  figures  are  now  almost  reversed,   with   Defense   27%   and
                                              DHEW 47%. "There  is  very  little  room  for  any  more  reordering  of
                                              priorities on a significant scale as  we  have  done  in  the  past  six
                                              years," he said.
                                                    I think we have to be patient with the obvious fact that we're  at
          Funding
                                              the low end of the roller coaster right now," said Ward.  Inflation  has
                                              hurt all health programs, "but inflation won't be with us  forever,  and
                                              we ve got to be ready-if  we  really  care  for  the  development  of  a
                                              fine health service in America-to run like heck  once  the  question  of
                                              inflation resolves itself. When the  chance  comes  to  really  get  the
                                              push back, then we've got to be prepared to move.  And  I  think  that's
                                              what we ought to set as our goal in the future."








         Twelve




                                                          The  Health  Planning  and  Resources  Development   Act   requir
                                                     that HSA governing  boards  be  made  up  of  a  majority  of  consume
                                                     a  fact  that  drew  thoughtful  and  provocative  comment   from   ma
                                                     speakers.
                                                         "We  (the  New  Orleans  CHP  agency)  supported   the   legislate
                                                     we believe it to be good legislation,"  said  Jones.  "It  places  maj
                                                     responsibilities at  the  local  area  and  that's  where  we  believe
                                                     should be. It maintains the  provision  for  consumer  majority  in  t
                                                     decision making process, and that's  as  we  believe  it  should  be.'
                                                         But  how  consumerism  can  best  contribute  to  effective   heal
                                                     planning  obviously  troubled  many.   Consumers,   Engebretson   note
                                                     have to be representative of the ethnic, linguistic and racial
                                                     norities, the sexual population and  special  groups  such  as  retire
                                                     persons, requiring  "judicious  selection  of  governing  body  member
               Control                               It may be difficult to recruit a seasonal farm worker to  serve  on  a
                                                     HSA  governing  body  who  would  lose  pay  and  may   possibly   mov
                                                     from location to location with the harvest. Rather the task  should  b
                                                     one of  selecting  someone  who  would  effectively  represent  the  i
                                                     terests of this population group."
                                                        "Many  people  may  say  that  we've  had  consumer  input  in   th
                                                     past and it just hasn't worked. You're right, it hasn't worked, but wh
                                                     hasn't it worked?," asked  Karen  I.  Shanor,  Ph.D.,  of  the  Nation
                                                     Center for Community  Action.  "Governing  boards  of  local  agencies
                                                     which by law have consumer majorities, all too often fail to reflect th
                                                     interest of  the  public.  The  General  Accounting  Office  has  foun
                                                     professionals such  as  retired  physicians,  administrators  at  home
                                                     for the aged and  directors  of  social  services  programs  listed  a
                                                     consumers.
                                                       "Conflicts  of  interest  abound,"  she  said,  and  consumers   are
                                                     often intimidated by the  sophistication  of  providers.  She  offered
                                                     suggestions  for  improvement  under  P.L.   93-641:   seek   consumer
                                                     representatives   through   community-based    organizations;    train
                                                     them, as well as providers ("because it  works  both  ways");  develop







            Fourteen



                                      par@:c@pa@:on  process;  hold  public  meetings   in
                                     locations to  encourage  real  participation;  enlist
                 or-st iiner@i  le@  colle:-t  needed  data;  develop  sub-area  councils;
                        that consumers will  be  nominated  for  the  state  health  coor-
                (-@iri,iting Council; rise consumer input in quality care criteria and  at
                all le,,'EIS of planning and implementation.
                     f:@ii,-hard Shoemaker, Assistant  Director  of  the  AFL-CIO  Depart-
                rTienL of Social Se--urity,  added  further  to  the  consumerism  debate.
                     P,I-ost health planning agencies, he said,  "are  afraid  of  consum-
                ers, ,-,ffective consumer representation.  Oh  yeah,  they  like  to  have
                them  on  the  boards  because  they  are   convenient   window   dressing
                bul iri terms of developing  effective  consumer  participation  into  the
                plani-.rg process I would say it's been a  dismal  failure.  Generally  in
                planrzrg bodies a  majority  of  consumer  representatives  is  like  hav-
                ir,g si),, lambs and four tigers. You know how that's going to turn out.       "Further control will b
                    "NDw I don't  want  to  be  completely  one-sided;  I  recognize  that     necessary, possibly in
                t@,e c(.)rsumer has  many  handicaps.  For  the  consumer  to  effectively     training, licensing and
                participate in the planning process takes a  great  deal  of  effort  away     reimbursement
                from i-ii!; normal activities."
                    Th(@  training  of  consumers,  he  said,  "is  a   matter   of   some     mechanisms." - Pickeft
                utgerc,/. It's completely unrealistic  to  think  that  the  providers  of
                healt@i (,are, any more than any other  group,  will  willingly  acquiesce
                to wr(.nching change. They  won't  willingly  offer  to  have  their  ser-
                vices eliminated or curtailed or even  modified  if  they  are  no  longer
                needed or if these services can be  performed  better  at  less  costs  by
                other ethods, individuals or institutions.  Neither  will  they  recognize
                these  facts  because  they  have  not  generally  understood  the   needs
                of corislimers."
                    Shoemaker   recommended    that    consumers    be    provided    with
                their own technical  staff,  a  practice  that  was  adopted  in  the  War
                Labor Board days of World War 11.
                    But  if  consumer  representatives  at  the  NARMP   Atlanta   meeting
                had concerns about the shape of things  to  come  with  P.  L.  93-641  so
                too did providers.





                                                  "I don't believe that the physicians  in  this  state  or  around  the
                                             country are  very  happy  about  the  way  the  law  was  finally  written,
        Provider ConcernS                    passed  and  signed  by  the  President,"  said   Adam   Jablonowski,   As-
                                             sistant Executive Director  of  the  Medical  Association  of  Georgia  and
                                             a representative of the American Medical Association.
                                                  "There  is  a  great  deal  of  concern   being   expressed   by   our
                                             physician members for  the  kinds  of  controls  that  are  envisioned-  in
                                             the law,  certainly  for  construction  and  expansion  of  hospitals,"  he
                                             said.
                                                   Another fear of physicians is  the  kind  of  service  controls  that
                                             the  law  envisions.  It's  probably  the  one  area  which  has  the  most
                                             emotional  impact  on  physicians.  They  are  very  concerned  that   some
                                             bureaucrat is going to tell  physicians  and  their  hospitals  whether  or
                                             not certain services can be performed in  a  particular  institution.  This
                                             obviously has a very  negative  kind  of  connotation  as  far  as  HSA  is
                                             concerned  for  physicians.  Another  concern  is   the   availability   of
                                             funds  for  the  development  of  changes  in  the  health  care   delivery
                                             system.
                                                  "Without individual physicians who  are  in  the  active  practice  of
                                             medicine participating on the board  of  directors,  I  don't  believe  the
                                             HSA will be able to succeed."



                               "I still have a lot of problems
                                 in my mind visualizing how
                                        the planner who is an
                                 innovator. . . can also be a
                                       developer, a practical
                                 administrator, a practicing
                                physician, and at the same
                                        time be a regulator."
                                                          - Barker









        Sixteen







               "The initial review responsibility  will  be  assigned  to  the  HSA.
           This provides a major opportunity  for  local  providers  to  help  state
           government  and  community  leadership  to   shape   a   more   effective    "And we're going to build
           health care delivery system," said  the  Hospital  Association's  Barker.   system in terms of plannin
               "Regulations are just not  going  to  fade  away  as  costs  continue          and resources withou
           to escalate,  as  the  demand  on  our  services  continues  to  multiply training of health manpowe
           and the expectations of our citizens continue to expand.                       Tha t is impossible.       H u n
               "The main issue is really how all  these  things  that  are  required
           by the law are going to fit. Whether we are going to  have  a  non-profit
           association  or  governmental  mechanism.  What  does  it  do  with   the
           doctor's office  practice,  with  the  institutional  services-all  these
           things are still kind of up in the air.
               "What for  example,  will  happen  when  a  new  hospital  is  needed
           and one of the requirements is  that  at  least  every  five  years  that
           institution is reviewed to see if it still needs to be in existence?  How
           can you arrange to borrow money  when  there  is  no  assurance  that  in
           five years that institution is going to be  needed  or  even  be  there?"
           he asked.
               "There are large  problems  ahead  of  us  unless  we  work  together
           to find alternative uses for structures and  for  institutions  as  needs
           change."
               "The  National  Kidney  Foundation,"  said   Hunt,   "is   worried-we
           are  concerned,  We  are  particularly  concerned  with  the   concentra-
           tion of the enormous amount  of  power  in  the  Secretary  of  HEW."  He
           recalled  that  regulations  for  the  end-stage  renal  disease  program
           authorized by the 1 972 Social  Security  Amendments  are  still  not  in
           final form.
               "But  that's  2-112  years  since  the  law  was  passed  and   these
           regulations still aren't out, and if  you're  worried  about  regulations
           being out for 93-641 then I think you should be.
               "I'm  concerned,"  Hunt  continued.  "Will  history  repeat   itself?
           RMP, CHIP  and  Hill-Burton  legislation  is  terminated.  It's  too  bad
           because these programs, particularly in  the  last  several  years,  have
           become extremely effective. The  RMP,  I  think,  has  served  more  than
           anything else  to  bring  the  private  sector  together.  The  voluntary
           health agencies have helped  bring  volunteers  together.  It's  too  bad
           that they didn't put together our expertise earlier."








                                                                                                             Seventeen









           Federal Role

                "I would hope that we had not gotten away from the concept  of                   "We    are     particularly
           regional   planning,"   Stevens   said,   "instead   of    mandating    im-           concerned     with      the
           mediately  the  concept  of  national  planning  ...  Whether  or  not   we          concentration     of     the
           can truly improve the  situation  with  the  authority  contained  in  this
           new  Act  to  me  remains  to  be  seen.  The   areawide,   statewide   and            enormous            amount
           nationwide   agencies   could   become   a   bureaucratic   nightmare    or                 of   power   in   the
           they  could   become   the   vehicle   for   developing   a   comprehensive           Secretary     of      HEW."
           health  care  services  program  through  the  cooperation  of   the   con-                                 -Hunt
           sumers, the providers and the government officials."
                "There  is  no  doubt,"  said  Simmons,  "that  the  Federal   govern-
           ment  must  assume  a  larger  role  in  the  development  of  health   re-                           "Government
           sources  and  in  making  certain  that  those  resources  effectively  re-              involvement          and
           spond  to  the  health  needs  of  the  American  people.  With  the  adop-               regulation    in    the
           tion of  national  health  insurance  even  under  an  essentially  private
           insurance  system,  the  involvement  of  the   Federal   government   will          health     care     industry
           be still greater than it is today."                                                            will      continue
                "All of us, in  government  and  out,  must  guard  against  the  ten-                        to grow.
           dency  for  necessary   and   proper   involvement   to   become   unneces-
           sary  encroachment  on   the   practice   of   medicine   and   the   whole                           -    Barker
           health  care  delivery  system.  Clearly  there  are  things  that  govern-
           ment can do best in the  health  field  .  .  .  but  individual  decisions
           involving  the  care  of  individual  patients  are  best   kept   out   of           "'When           government
           bureaucratic  hands  whenever  possible.  It  would   be   tragically   un-              makes     a     mistake,
           wise for any of  us  to  assume  that  policy,  good  or  bad,  can  be  or
           should be framed by government alone."                                                         the    whole    of
                "RMP," Simmons  said,  "did  do  a  good  deal  of  work  and  it  did         society     suffers,      and
           do a lot of network creating, and  it  did  have  innovation,  and  it  had                every       individual
           some remarkable effects. Now,  I  believe  that  the  scope  of  the  prob-
           lems in the government will require  every  bit  of  talent  that  RMP  has         and   institution   in   it."
           left over."                                                                                              -Simmons








                                                                                                                   Nineteen














                                                                                   in
                  The costs of medical and health  care,  a  basic  consideration  '
             the new law, caused a great deal of discussion in Atlanta.  along  with
             public accountability.
                   Health planning in this  country  needs  public  accountability,"
             declared Michael K. Gemell,  legislative  representative  for  the  Na-
             tional Association of Counties. In following the legislation as it  de-
             veloped in Congress, he said,  "we  wanted  to  stress  that  governors
             should be given the option to designate  private,  non-profit  corpora-
             tions, regional councils of government or  a  single  unit  of  general
             purpose  government  to  do  the  health  planning  and  be  designated
             the HSA." The concept  won,  Gemell  said,  but  there  remain  differ-
             ences in interpretation between  Congress  and  DHEW  as  to  what  the
             law intends.
                 "Who  will  appoint  the  governing  bodies  in   the   HSAS?"   he
             asked. "That's a question not answered in the  law.  We  maintain  that
             local elected officials are the ones  best  to  appoint.  Nobody  seems
             to understand that public accountability can only rest, we think,  with
             the local elected officials."
                Edward  Mearns,  Professor  of   Law   at   Case   Western   Reserve
             University,  and  a  legal  advocacy  representative,   offered   these
             comments:
                "When I  say  my  reasonable  expectations  are  assured  access  to
             adequate care on a more equitable  basis,  I  think  I  recognize  that
             this has to be achieved  even  at  the  expense  of  perhaps  offending
             some of  the  ideologues  who  would  maintain  a  present  balance  of
             the private and public roles in health care delivery.
                "At some  point  the  consumers,  the  non-professionals,  the  rest
             of us have  to  say  something  about  developing  the  instruments  to
             achieve public accountability. We've got a  terrible  struggle  to  get
             the consumer aware. I think the consumer  is  only  moved  to  perceive
             inadequacies from the actual delivery of care,  and  is  not  concerned
             with patiently observing experiments  in  decision-making  or  in  pro-
             cedure.







          Twenty


















 WIL





                                                                      When    it    comes     to     making     choices     on     costs,     saidA,FF.           k-
                                                               ett,  "the provider has a ready and expensive answer: the                                        "ier
             'value@ Conflicts
                                                               really   has   the   responsibility   and    he    will    pay    for    that    answei,
                                                               makes   it.   To   deal   with    such    problems    effectively    we    will    ha@,(        .i. r n
                                                               about    negotiating    quality     rather     than     assuming     it     simply     a
                                                               We'll   have    to    chance    shifting    control    from    providers    to    cori,,   T I r S.
                                                                      The   priorities   in    the    new    Act,    he    continued,    are    "laucl.        @l.nd
                                                               acceptable    ...    but    are    in    conflict    with     one     another.     Betl,     i@-i@@)re
                                                                                                                                                                 ti-
                                                               equal    access     and     higher     quality     simply     cannot     be     obtaine.
             "Taken to  ether, our new                         cally   at   a   lower   cost,   even    at    the    same    cost.    Something    he.@  iD       e,
                             9
                                                               some value.
             national priorities are in
                                                                      "To   make    any    real    progress    in    achieving    the    goals    en@,,  -,erGIed
             d.,.,onflict, with one another.
                                                               by     Congress,     a     substantial     expansion     and     change     in     cont.
             ..@Pickeff                                        be    necessary.    It's    not     clear     that     this     would     ultimately     iE@a@-     a
                                                               government-managed     national     health     insurance     but      it      is      cl           if
                                                               all   the   priorities   were   to    be    attained,    control    of    the    indus',    ,vc-iijld
                                                               have    to    be    wrested    from     the     providers     and     transferred     to  ie     con-
                                                               sumers,      who      would       hopefully       combine       democratic       humanism       ",ith
                                                               managerial   rationalism.   If    this    really    happened,    it    is    hoped    ',,',al    cov-
                                                               ernment    will    broker    the    transfer    and     not     assume     unto     itse  the     ar-
                                                               rogance of control. We may not like the results."






             Twenty Two



















                                                                Timetable




              The timetable in Public Law  93-641,  which  has  legislative  au-
          thority extending through June 30, 1 977, begins with the  area  boun-
          dary designation, a process likely to be largely cortipleted  in  late
          @ummer, followed by HSA formation
              "It will be possible," said Gerald T. Gardell, Acting Director  of
          the Division  of  Regior,@al  Medical  Programs,  "to  establish  many
          @ealth  systems  agencies  by  January,  principally  in   homogeneous
          ,ural areas such as the upper  peninsula  of  Michigan  and  in  those
          states which will have a statewide HSA, and in those  areas  where  an
          existing agency-CHP(b) or RMP-transfers itself into the HSA.
              "Formation of HSAs  by  January  1  is  unlikely  in  those  areas
          where there are likely to be competing applicants,  where  there  have
          been major  metropolitan  areas  such  as  New  York,  San  Francisco,
          Boston, Chicago and Detroit."







                                                                                                       Twenty Three


wr@@












                                                                   to  contribute   sub-
                 Once HSAs are in place they are expected
            stantially to an effective national health insurance  and  to  the  Nation's
            developing health policy.
                 Flood, listing  his  own  personal  priorities,  chose  first  a  mech-
            anism for resources development -"filling gaps, seeing       that   patients
            get service  where  it  doesn't  exist   now"-followed   by   the   national
             riorities set forth in the new law and national health insurance.
            p
                 "Congress  knows  that   we   need   national   health   insurance.   I
            think it is a plus for  the  lawmakers,  however,  that  they  have  debated
            over several years  how  to  provide  that  insurance.  It  is  complicated.
            The  infusion  of  gobs  of  new  money  into  our  health   care   delivery
            system could have catastrophic price results.
                "The real answer, of  course,  is  prevention,"  he  said,  adding  that
            he  hoped  the  Public  Health   Service   Commissioned   Corps   could   be
            put "back at work at prevention of disease."
                National  health  insurance,  said  Hastings,  "will  come   next   year
                                                                      cost.
            in some form." But he, too, expressed concern about                 Everyone
            seems to want in it access to everything available, he        said.      "My
            friends  we'd  better  understand  one  thing  once  we  start  writing  na-
            tional health insurance: there is not enough money in         the      whole
            world to make  those  kinds  of  promises  and  then  deliver."
               "Once  we  do  have  a   national   health   insurance   program,"   said
            Jablonowski,  "and   all   the   elements   are   successfully   functioning
            there obviously will have to be some kind of formulation     of     national
            health  policy,  and  I  believe  that  physicians  should  carve  out   for
            themselves a role  in  the  formulation  of  this  national  health  policy.
            They  must  have  a  strong  voice  in  the  development  of   such   policy
            and  its  implementation.  This  obviously  means   participation   on   all
            levels  in  the  development  of  HSAS,  of  both  providers   and   consum-
            ers, and I think they can work together."





        Twenty Four







      National Health Insurance































                                                                                                               Twenty Five











                                                         "There    i sno fir-.-al oi-Pcle on national  @iealtf-i  [)olicy,  no  highest
                                                                                              I                I @
                                                    officeorcourtof last resort," said 3'mriori@,;. "Wc-,'i      the   United    States
                                                    have not given tha;' distinction to anyone cr                  institution.     And
                                                    frankly I hope we nc-2ver do."
                                                         "We have taken a sif-riDlistic attitu(Je  toward  @--i..-itional  health  pol-
           Health Policl@f                          icy in the last two dc@@cade      We    assumed    that    isolated,     fragmented
                                                    programs at the F(@(ieral            world   Somehow   3(@lve   a   multitude    of
                                                    problems,"
                                                         "It didi,,'t work. ['low -AiE,-, feel sense of u,gE@i,-i y.  Not   only   have
                                                                                                                 ied   on   them,   but
                                                    past efforts   proveri jnecl,-,al to       hopes we
                                                    even more to the po nt national  h@'.,alth  inSL]r-ari(,',E@.  Nhen  it  comes,  is
                                                    sure to impose a st@r@.lin on the  he@'Ith  care  s,yster-ri  the  likes  of  which
                                                    we have never befo!e ex,@erienc(@@I."
                                                         National  healt'ri  insurance,  sa'd  Mearns,  "is  c  (@)ing  to  come   with
                                                    planning that's prett,,,, primitive. Tf-,e big feai- for  rTie  is  that  it  comes
                                                    when we are riot ready,  that  -we  w  11  do  again  w@,,a'  we  do  so  often  in
                                                    this  country-proc'Lj(;e  the  expectation  in  those   dwellers   in   the   inner
                                                    cities,  the   expectati,")n   of   t@ose   rural   areas   where   services   have
                                                    been inadequate or i-ion-exi,,:;tent. I do not view wi      'h   great   calm   the
                                                    creating  once  again  of   Iiig@i   hopes   which   are   riot   met,   when   the
                                                    services are not there."
                                                         "It's  time  to  put  behind  debate  on  issues  raised   in   the   develop-
                                                    ment  of  Public   Law   93-641,"   said   Jones.   "T@iis   may   be   and   quite
                                                    likely  is  the  last  opportunity  we  have  for   local   decision-making   about
                                                    allocation  of  our  health  resources  in  this  country.  The   continuation   of
                                                    negative  rhetoric  will  not  serve  our  purposes  and   will   not   serve   the
                                                    health  care  consumers  of  the  Nation.  It  could,   however,   well   serve   a
                                                    strategy   which   will   lead   to   the   complete    Federal    domination    of
                                                    health planning in this Nation."







         Twenty Six













            "We  can  coordinate,  we  can   pul@   lay   and   professional   volun-
        teers together,  we  can  do  studies,  we  can  define  means,  particularly
        in terms of facilities and so on,"  said  Hunt.  "Especially  we  should  get
        back  and  work  together  with  you,  the  professionals  in  administration
        who have capabilities that  we  don't  have,  particularly  in  this  interim
        period.  We  must  make  this  legislation  work  because  it   probably   is
        the last chance the private sectors are going  to  have  not  to  be  totally
        controlled by the government."
             "Unless  we  want  doctors'  strikes,  staff  revolts  or  hospital  ad-
        ministrators   becoming   as   transient   as   college   presidents,"   said
        Flood,  "then  we'd  better  not  pose  radical   changes   in   our   health
        system."
             "I  believe  in  a  patient  being  allowed  to  choose  his  doctor.  I
        believe that for the demonstrably ill as well as for the worried well  it  is
        essential that  a  doctor  know  the  whole  patient  and  that  the  patient
        have confidence in his  doctor.  Those  are  essential  parts  of  the  cure,
        you know."
             "America  has  generally  avoided  the  excess  of  the  right  and  the
        left,  the  over-regimentation  some  countries  have  perpetrated.  I   want
        her  to  avoid  excessive  change  in  medicine  as  well.  We  are   experi-
        menting   slowly   with   Health   Maintenance   Organizations   and    other
        systems.  This  is  an  era  of  world-wide   over-rapid   and   often   mis-
        directed change. If  we  watch  our  priorities,  attend  to  highly  visible
        resource   development   needs,   and   rebuild   our   disease    prevention
        army then I think we  will  be  able  to  afford  national  health  insurance
        and  we'll  live  to  see  our  medical  care  system  become  as   good   as
        the best anywhere."






                                                                                                             Twenty E)even















                                                                                                                                  Program Committee

                                                                                                                          James W. Culbertson, M.D., Chairman
                                                                                                                          Memphis  Regional   Medical   Program
                                                                                                                          Harry Auerbach
                                                                                                                          III nois Reg onal Med cal Program

                                                                                                                          Donald G. Brekke
                                                                              National Association                        South Dakota Regional Med@ca Program
                                                                        Of Regional Medical Programs                      Evangeline L. Hebbler, M.P.H.
                                                                                                                          Oh o Valley Regional Medical Program
                                                                               Board of Directors                         Granville Larimore, M.D.
                                                                                                                          Florida Regional Med cal Program
                                                                        John R. F. Ingall, M.D. Chairman                  Robert Miller
                                                                        Buffalo, New York                                 Northeastern Regional Medical Programs
                                                                        J. Gordon Barrow, M.D.                            John A. Mitchell, M.D.
                                                                        Atlanta, Georgia                                  California Regional  Medical  Program
                                                                        Robert W. Brown, M.D.                             J.S. Reinschmidt, M.D.
                                                                        Kansas City, Kansas                               Oregon Regional Medical Program
                                                                        Charles W. Caldwell                               J.A. Sabatier, Jr., M.D.
                                                                        Oakdale, Iowa                                     Louisiana  Regional  Medical  Program
                                                                        James W. Culbertson, M.D.                         Samuel Sherman, M.D.
                                                                        Memphis, Tennessee                                California Regional  Medical  Program
                                                                        Robert P. Lawton                                  Roger J. Warner
                                                                        Cranston, Rhode Island                            Arkansas  Regional  Medical   Program
                                                                        Benjamin Morgan                                   Charles White, Ph.D.
                                                                        Buffalo, New York                                 California Regional  Medical  Program
                                                                        Donal R. Sparkman, M.D.                           Robert A. Younqerman, J.D.
                                                                        Seattle, Washington                               Southeastern Regional Medical Programs
                                                                        Paul D. Ward                                      Nathaniel Polster, Consultant
                                                                        Oakland, California                               Government Information Representative









             Twenty Eight




















              Public Information Committee


              William Boquist, Chairman
              Calitorn@a Regiona@ Med cal Program

              Edna Carroll
              B -State Regional Medical Program

              Frederick E. Frazier
              Missouri Regional Medical Program

              Gerald N. Gold
              New Jersey Reg onai Med ca Program

              Dennis E. McClendon
              Florida Regiona Medical Program
              Sylvia Sterne
              Louisiana Regional Med ca Program















            Photographs by Steve F McCourtie, Linda R. Johnston and Donald Trantow Sketches by Robert C Hunt, Book Design and production by Pat Cunningha