Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 55
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 -
OCR for page 56
- 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
OCR for page 57
- 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.
OCR for page 58
- 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
OCR for page 59
- 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.
OCR for page 60
- 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.
OCR for page 61
- 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.
OCR for page 62
- 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.
. ~ . . . .
Representative terms from entire chapter:
planning program
