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CHAPTER I INTRODUCTION For the past two years, a committee of the Institute of Medicine has examined policy issues related to the nation's current health plan- ning program at the request of the Health Resources Administration, in the U. S. Department of Health and Human Services (DHHS). This volume covers the committee's work in the second year of the study on two important, timely issues: national, state and local roles and re- lationships in health planning and the participation of "consumers"* in the advisory roles given to the planning agencies. A previous volume, Health Planning in the United States: Issues in Guideline Development (Institute of Medicine, 1980), dealt with policy questions related directly to the development of national health planning goals and standards, and described a theoretical framework for examining the health planning program. The first volume reviewed the literature and the history of health planning in the United States. At the end of its first year's work, the committee made specific recommendations to the Health Resources Administration on the possible use of national health planning guidelines as instruments for the establishment and promulgation of public policy. The committee ob- served that in a heterogeneous society that values the collaborative, bargaining mode of policymaking, the process of creating guidelines is itself important. The committee asserted that the guidelines should: (a) result from a systematic and highly participatory process; (b) be on as firm an empirical base as possible; (c) be disseminated with rel- evant documentation; and (d) be developed with advisories on agenda setting and priorities from the National Council on Health Planning and Development. The Council should, it was concluded, be given an expanded and strengthened role. *The language of P.L. 93-641, stipulates consumers, consumer majority, and consumer participation, but means lay citizens. The terms reflect the distinction between "providers" of health care and their opposites, "consumers." 1

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2 The Health Resources Administration (HRA) then requested that the Institute of Medicine committee spend another year analyzing problems related to consumer involvement and intergovernmental and private agen- cy relationships. Their request was made partly on the basis of the urgency of some of the policy issues and HRA's desire for advice from an independent institution on those particularly important, thorny sub- jects. Although the focus of the study in the second year is on those two broad issues, the committee found it impossible to talk about effective consumer participation or productive national, state, and local relationships without some agreement on the purposes of the health planning program, and a vision of what would be considered an effective program or an effective participant in it. This report there- fore also contains a discussion of the committee's perspective on the entire program. The charge to the committee in the second year was (1) to identify issues in national, state, and local roles and relationships and con- sumer participation that affect the health planning program; (2) to discuss alternative approaches to a more effective program; and (3) to make specific recommendations or comments concerning the issues raised. In the second year, the committee's objectives included the following: (1) to clarify the issues and expand the knowledge base, thus assisting the Health Resources Administration in preparing, re- taining and revising policies and guidelines on consumer participation and national, state, and local relationships in health planning, (2) to assist Health Systems Agencies, Statewide Health Coordinating Councils and State Health Planning and Development Agencies in fostering the most effective linkages with each other and other agencies; (3) to identify sources of tension that negatively affect the program and make recommendations for their amelioration; and (4) to improve the theore- tical and empirical foundations for understanding health planning and regulation. Activities In the second year, the committee conducted a review of the liter- ature, held public hearings and commissioned ten background papers. The pertinent literature on health planning and regulation was selec- tively examined with particular attention to studies of consumer par- ticipation and national, state, and local relationships. Early in the second year of the study, March 27, 1980, a public hearing was held at the National Academy of Sciences.* More than 600 *This was actually the committee's second public hearing. The first (March 1979) was concerned primarily with the national health plan- ning goals and standards.

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- 3 - persons and organizations were invited to present their testimony to the committee, based on a list of questions on which the committee was seeking advice. That list is in the Appendix with a roster of those who submitted written statements to the committee. The committee was particularly interested in the positions of representative organizations of consumers, public interest groups, and public officials. Their participation was actively sought, and many presented testimony. The committee also commissioned ten papers on aspects of the study: The papers and the authors are: Lawrence Brown, Ph.~.--"Struc- tural Issues in National, State, and Local Relations in Health Plan- ning;" Barry Checkoway, Ph.D.--"Consumerism in Health Planning Agen- cies," and "Consumer Movements in Health Planning;" Donald Cohodes, Ph.D.--"Interstate Variation in Certificate of Need Programs - A Review and Prospectus;" George Downs, Ph.D.--"Monitoring the Health Planning System: Data, Measurement and Inference Problems;" Dorothy Ellenburg- -"Special Interests Versus Citizen Control: Who Owns Planning?" James Morone--"The Real World of Representation: Consumers and che HSAs," and "Models of Representation: Consumers and the HSAs" ;' Gregory Raab, Ph.D.--"National, State, and Local Relationships in Health Planning: Interest Group Reaction and Lobbying;" and Harvey Sapolsky, Ph.D.-- "Bottoms Up is Upside Down". They constitute Volume II of this report and are referenced simply by authors' name in this volume. Impressions from health planners working in agencies throughout the country were garnered from a discussion arranged by two committee members, at the Annual Meeting of the American Health Planning Associa- tion. More than 30 planning agency board members and planners partici- pated. The committee met five times in this second study period. In addition, two groups of authors met with representatives of the com- mittee to discuss the papers at an early stage. The authors also met for a one-day session with the full committee before the preparation of the committee's recommendations. As in the first year, the committee and staff visited health plan- ning agencies, met with governing body members and staff, routinely reviewed agency reports, Health Systems Plans, and attended selected training activities. Organization of the Report This report has two volumes. Volume I, the committee's policy statement, has five chapters. Chapter II provides a short overview of the health planning program. It discusses some of the general issues concerning topics covered in detail in Chapters III and IV, and pro- vides background information on the purposes of the health planning

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4 - program and approaches to assessing its effectiveness. Chapter III con- tains the committee's findings and recommendations concerning national, state, and local relations in health planning. Chapter IV has the com- mittee's observations and recommendations on consumer participation. Chapter ~ is a summary of key findings and the recommendations. Volume II is composed of the background papers commissioned by the committee. They detail the empirical and theoretical underpinnings of the study. The authors were encouraged to express their opinions and make their own recommendations. The papers, although reviewed by the Academy, are not submitted to the same review process as committee reports and represent the views of the individual authors, not the committee or the Institute of Medicine. The committee feels that the papers by themselves constitute major contributions to the quality of current debates in health planning and should be disseminated broadly.