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CHAPTER V SUMMARY OF RECOMMENDATIONS This chapter contains a summary of the committee's recommendations, but the data and argumentation supporting the recommendations are pre- sented in the body of the report. In Chapters I, II, and III, the commit- tee presents the background, the approach of the study, the rationale for the recommendations, and additional observations. As stated on page 3, the Institute was asked (a) to examine the policy and research issues related to the national health planning guidelines, and (b) to recommend methods for developing guidelines. The methods are to help ensure that future goals and standards (the Act's definition of guidelines) benefit from the best advice, are as defensible as possible on scientific grounds, are open to public and professional scrutiny before issuance' and are flexible enough to permit re-examination and revision as new knowledge becomes available. Chapters II and III contain the results of the committee's review and subsequent judgments about the guidelines. Chapter IV contains the committee's observations and judgments for an improved process for development of guidelines. The committee decided at the outset that its work toward facilitat- ing the development of guidelines for future national health planning required an overall examination of existing health planning activities and related policy issues. The committee was particularly concerned that the planning program has been challenged since its inception by those who call for less or no governmental intervention in the health sector and by others who feel that more stringent governmental controls are needed, as well as by some who note problems in implementation. The current health planning program--a mixture of planning and regulation--will not consistently satisfy proponents of either less regulation or more regulation. This complicated nationwide program introduces regulatory controls and community-wide planning into a primarily private system. It also cuts across many of the health system's difficult, value laden, and controversial problems. Decisions made by local planning agencies are sometimes overruled by legislative or executive branches of state government because of political - 55 -

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- 56 - considerations. Conversely, sometimes the more technical, defensible judgments are found at the state level rather than by the local agency. In addition, some planning agencies have been hampered by severe admin- istrative difficulties, such as those that led to the Recertification of the Los Angeles health system agency. Programs that are interjected into a complex matrix of public-private tensions, intergovernmental relations, and struggles between rationality, community preferences, and political decision making are not likely to mature gracefully. For these reasons, this committee believes that the difficulties of implementing and assessing such social programs should be appreciated. The committee recognizes that the planning effort thus far has enlisted persons of competence and sensitivity in a difficult enterprise. The committee is also aware that some viewers of the planning program from some communities or states have anecdotal evidence of power struggles, staffing inadequacies, and limited public interest that brings into question many of the ideals of the program. Health planning involves some 260 agencies and thousands of human beings; hence, unevenness of development and the absence of perfect functioning are not surprising. The mission of the agencies would be difficult under the very best circumstances. Whether one agrees that this particular planning program is the best approach, one can at least concede the value of allowing this approach--the products of very explicit and thoroughly discussed political decisions--to be adequately tested and examined before changes are made. Without a fair test, we will never know what can work and what cannot. The National Health Planning Act calls for national guidelines and program administration at the federal level and planning to be conducted at the local level, shaped by state concerns and interests. This circumstance offers an opportunity for study of what does and does not work in planning at the local level. Changes in the program can be made later, on the basis of knowledge and experience, rather than speculation. The Planning Program After reviewing the planning program, the committee concludes that the current health plannning program has substantial potential for helping to achieve certain important social goals, through local planning for improved local health care systems. The committee is con- cerned about about a common tendency to look for evidence of effective- ness too early in social programs, especially when hopes about a program are high. The committee urges recognition of the difficulties of evaluating complex social programs. Different emphasis is given by various people to the multiple, sometimes conflicting, goals of the health planning program. The planning program was designed to help

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- 57 - determine on a local level and in a public forum what health resources should be developed or modified in the future in each community. As it tries to balance cost containment with improvement of quality, access, and equity, the planning program will not consistently satisfy anyone. The challenge and complexity of the planning process is the interrela- tion of differing interests and the difficult search for reconciliation. But, the health planning program is well-suited for determining and expressing the health care aspirations of consumers and providers in a given geographic area for improving the provision of health care to the various parts of the community. It is the committee's judgment that there is insufficient evidence about planning or capital invest- ment controls under certificate of need to warrant significant changes in the program at this time. The Congress, other policymakers, and program administrators should recognize the limitations of available evidence for public policy judgments. The committee urges attention to, and support for, the kinds of evaluative studies that will provide a rational basis for any modifications in the program at the end of the next three years. This is discussed in Chapter II. The committee recommends that the limitations of HSAs in reduc- ing health care expenditures be recognized, because unrealistic expectations are likely to lead to the conclusion that the program has not succeeded. The committee recommends that the planning agencies be judged according to a broad set of measures including measures of improvement in access, quality, and equity, not only cost moderation. The broad strategy is more suited to their statutory mandate. As an intermediate approach, the committee believes that certain measures of the desirable characteristics of the process of health planning, mandated by the law, can be identified to assess and monitor the planning program as it is being put into place. However, the committee feels strongly that efforts should be undertaken simultaneously to define goals of the program more concretely and develop quantitative measures of effectiveness as soon as possible. The intermediate measures of effectiveness should include: whether the HSA provides a useful forum for public policy discussion; whether it serves as a source of information about local health care problems and steps being taken to deal with them; whether it has credibility in the community; whether appropriate data and analytical methods are being employed as a basis for conclusions; whether the HSA is serving as an effective agent in helping to improve the health care services received by the public and promoting health care for the area's residents at an acceptable level of cost; whether health care consumers and providers are being involved in improving the system; and whether the HSA is catalyzing problems of the underserved or underrepresented. Specific indicators that quantify those characteristics are needed. But there was not adequate time during this study to begin that task. In addition, useful measures of the effects and of the possible effectiveness of the planning program are needed.

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- 58 - National Guidelines The planning program is a mechanism aimed at improving the process of making public policy and does not itself propose any single approach in the search for answers. Precisely what kind and combination of planning, resources development, regulation, fostering of competition, cost control, and the like emerges at the local level will be partly dependent on local conditions and the choices made by each community. The delivery of health care is predominantly local in nature, and deci- sions concerning the most effective arrangements are best made at the local level within broad federal guidance, in recognition of the signifi- cance of the federal involvement, especially in financing health care. As discussed in detail in Chapter III, the committee believes that there is an important role for a national health planning policy. The federal government has an important stake in what happens at the local level, both because of its role in ensuring equity and access, and its role as a major financer of services. For the federal perspective and requirements to be directly and clearly expressed, the planning act contains positive and negative incentives to encourage movement in directions acceptable to the federal government. The committee believes that the national health planning guidelines provide a promising opportunity to express national interests and concerns and can help achieve a more effective allocation of health resources. The committee believes that properly formulated national guidelines can help identify a more equitable allocation of resources among localities, and allow for local variations in needs and preferences, while advancing toward an equitable "minimum" level of health care for the entire nation and toward comparable levels of prudent health resource management. Some areas of the United States have substantial health resources and other areas few. Guidelines, including normative resources standards, can be used to set targets and to measure progress toward a more equitable, but not necessarily uniform, distribution nationally. While the committee believes that the national guidelines serve important national interests, it also believes that guidelines are an essential and useful part of local and state planning, if applied flexibly. They can be aids to local planning as indices of comparison, as benchmarks, and as quantitative measures for expressing national health planning priorities. The committee recommends that guidelines be promulgated with documentation of their bases including, where applicable, the methods and data used for their development. Com- plete documentation should enhance credibility, increase use, and strengthen local planners' abilities to plan well and negotiate sensitively. (See Chapters III and IV.) The Act defines the guidelines as health planning goals and re- source standards, but areawide planning is an intricate process, influenced by local conditions and aspirations. No one, including the

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- 59 - federal government, is able to articulate what health services arrange- ments will work in each community. The committee concluded that useful guidelines can take a variety of forms, including indicators of health policy direction, statements of principle, process guidelines, as well as goals and resource standards. This would permit promulgation of policies that are important but about which there is insufficient cer- tainty, or consensus, for formulating specific goals or standards (such as for care of the elderly), or where the public process is seen as preeminently important. For example, in examining guidelines for long-term care for the elderly, the committee was reminded that making policies or regulations in any one area has other effects, and in making specific guidelines administrators must be sensitive to such effects. The committee noted that guidelines development would most sensitively be undertaken within a framework of broad principles that express the complexity of the topics, and express some of the important environmen- tal factors and pertinent policy problems. The committee observed in its study of access to health care that some minimum level goals and guidelines on the process of planning for access would be useful, but it also emphasized that better goals and standards should be developed at the local level. From its study of guidelines in the configuration of hospital services, the committee concludes that, for some problems, process guidelines should be developed. For instance, acute care hospitals should be required to describe their programs, and their program's compatibility with other hospitals in their community, as part of the plan development or appropriateness review function of the HSA. This guideline would bring hospital administrators and trustees face to face with other community interests involved in the planning process, foster the view that individual hospital programs should not be viewed independently of others, and encourage better institutional planning. The committee believes that guidelines should encourage changes in capacity that improve the appropriateness of services available. Although reducing bed capacity is not suitable as a goal by itself, the committee believes that excess capacity has no redeeming utility and efforts should be made to eliminate it. The inappropriate use of acute care beds should be regarded as excess. However, reduction should not be undertaken without consideration of overall needs and assessment of the availability of alternatives. In all approaches, the committee feels that guidelines should be flexible and responsive to changes in the knowledge base, in the nature of the data, in the need to use judgment, and in results of evaluation. The committee believes that if resource standards are issued, guidelines formulation should begin with related health goals. Health goals provide a direction for planning for health services in an area and may enhance their coherence, increase opportunities for innovation, and, when numerical standards are involved, help avoid misunderstandings about the purposes of the standards.

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- 60 - Although there is value in the guidelines having other forms, the committee believes that resource standards, as one subset or form of guidelines, can be useful. For example, guidelines in the form of resource standards for acute hospitals exist and should be expanded selectively to cover other services and facilities, such as intensive care units. All such standards should be developed after careful review of the most appropriate type of guidelines for the problem and should be subjected to periodic reappraisal and possible modification. The committee's opinion is that, while standards may not be advisable in some areas of health planning, numerical standards for acute care facilities and services are useful. Numerical standards can be useful as benchmarks or tools to help planners, especially on matters about which there is consensus, such as hospital beds. But the committee recommends that goals and standards be promulgated more often in the form of ranges, rather than single numbers, with explicit discussion of what variations within that range might be reasonable and why. The intent would be to provide the planners with technical tools to assist in policy decisions at the local level and to help guide negotiations within defined boundaries. In addition, the importance of the inter-relationships among services and the effects of substitution among them should be made as clear as possible. The Process for Developing National Guidelines Because the guidelines are a means for establishing and express- ing national interests at local and state levels, and for helping the planning agencies to strengthen their knowledge and negotiating ability, it is the committee's judgment that the process by which the national guidelines are developed is important. The committee believes that an open and collaborative development of guidelines will minimize areas of disagreement and enhance the use- fulness, quality, and acceptability of the guidelines. The process, methods used, and the technical and professional quality of the guide- lines are important. Thoughtful and systematic examination of exist- ing knowledge and the judgments of experts must be brought together in public and open process. While this emphasis on the methods of development may seem un- necessary or overdrawn, the committee is trying to make clear what it discerned through analysis of the evidence and interviews, that the process (as is true in democracy) is itself important. Professional assistance was not sought and credible experts were not used in the first round by DREW and mistakes that were made should not have been.* a *This was primarily because a subset of possible standards and goals, which were under study, was actually issued. The elaborate preparatory work that had been undertaken by DREW staff was not taken into account when the decision was made to issue only some of the standards--the most controversial ones--aimed at cost control.

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- 61 - It is not unusual for governmental staff to develop policies, regula- tions, and procedures in a manner contrary to all that is said in this report. Those statements are not obvious to such staff, despite appear- ances, and these principles have not guided.actual guidelines develop- ment. The report reminds that certain.procedures, practices, and principles are worth-following. The committee lacks confidence that without such statements and.some periodic vigilance by non-government entitites, such principles will remain as important guidelines for the future. The committee concludes that an overall.system of priorities for development is essential to the guideline development process. An agenda for development of guidelines must take into account the needs and interests of planning agencies, consumers, providers, payers, and key participants in the health system. Solicitation of opinion and participation is important and can best be managed by a group connected to the planning program, but not associated with any single perspective. Agenda development is one aspect of the guidelines process in which the committee believes the.National Council on Health. Planning and Development can play an important role in assisting the Secretary.* The Council, representatives of a variety of interests in the health field, is a suitable body to guide the process of agenda development. The committee recommends that the National Council, which is established and operational, be asked to recommend to the Secretary of Health, Education, and Welfare. an agenda for guidelines development, including priorities. The Council would consider the special interests and concerns of the federal government as major factors influencing . . their recommendations for an agenda, but also would seek advice from health planning agencies.and other participants in the health system. . . . . . To ensure the proper development.of an agenda and continued use- ful advice on related activities,. the committee recommends that the Council be given an adequate staff, some of whom should be full-time with the Council, who report directly to it. The process of developing guidelines, as contrasted to the agenda, should remain in the Department of Health, Education, and Welfare, but *The committee did not prepare a recommendation on the location of guidelines development within the Department of Health, Education, and Welfare, because the committee felt that commenting on specific location within DREW was not appropriate. The Congressional intent to develop a federal planning process that would work toward a more con- sistent set of federal health policies demands the active collabora- tion of many parts of DREW. Thus, the nature of the responsibility suggests that it should be at a high level in the Department. Such placement would also facilitate cooperation for federal health plan- ning that involves other parts of government including the Depart- ments of Defense and Agriculture, and the Veterans Administration.

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- 62 - the National Council should have a specified role in advising on that process and be called as an adviser for both the content and the pro- cess aspects of guidelines development. For developing the guidelines, the committee recommends that ade- quate staff within DREW be assigned to that important activity, and that adequacy be recognized as being both a quantitative and qualita- tive concept. The committee also recommends the use of consensus devel- opment groups of appropriate technical and operational experts. The consensus development groups would build upon, and coordinate with, clinical and technology assessments under the National Center for Health Care Technology, the National Institutes of Health, and reim- bursement policy studies of the Health Care Financing Administration. Department-wide collaboration would be enhanced if the function is in the Office of the Secretary. The committee believes that the entire process of guidelines devel- opment (from agenda development through evaluation and revision) should be organized in consultation with the National Council on Health Plan- ning and Development to ensure broad public participation and selection of a broadly representative set of perspectives and interests as appro- priate to each problem. The committee believes that the National Council must become a significant resource as an adviser and as a public forum for improving the effectiveness of the planning process and its role should be strengthened. The Council will be more effective with a small staff of its own selection and supervision. It is recognized that administrative agencies do not always welcome advisory bodies, espe- cially those with their own staff, but the Council is a logical place for certain activities (such as bringing together various interests and perspectives), is fully operational (a process that usually takes many months), and has a firm statutory base. Over the long run, it is in the interest of the Department to have an effective Council to help improve the quality of the planning enterprise. Sometimes there will be tension, but most often, the purposes of the planning program and the public interest will be served when the Council and the Department work co- operatively and sensitively with each other. . ~ . . . .