Health Planning in the United States Issues in Guideline Development, Report of a Study (1980) / Chapter Skim
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II. Overview
II. Overview
Pages 7-28
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O What is the role of health planning in the health care system? O What is the evidence concerning the effectiveness of past health planning programs?
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Health planning offers no single prescription or specific answers. It is not regulation, although the current program has some regulatory authority at the state level.
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Credibility and acceptability of this kind of planning, especially for facilities, was imparted by its involvement with philanthropic, business and industrial leaders. The committee finds that the most persuasive case for health planning rests on the divergence of interests of autonomous providers and the broader public (Klarman, 1978~.
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and was regarded as a gain with the 1974 planning legislation. Although planning and regulation are intermingled in the planning program, there are real differences between the two concepts.
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The 1974 Act gave planning a prominent role, with limited regulatory controls over capital investment for institutions at the state level. The law also gave HSAs advisory authority to review and approve or disapprove the proposed use of selected federal funds for health projects.
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Planning, as a process, can be developed along many lines, including planning without any regulation. The health planning program, and particularly the regulatory authority in it, has not been exempt from criticism.
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Health planning began and has remained largely in the private, non-profit sector, with private citizens deciding what buildings or equipment are desired for medical services in a given community (Gottlieb, 1974~. The Hill-Burton Program The first significant involvement of the federal government in health planning began in 1946 with the Hospital Survey and Construction Act -- the Hill-Burton program.
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Also during the 1960s, community action agencies developed community health centers. Two features of those were important to the history of health planning.
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At the state level, health planning often consisted of routine paper work, a necessary annual precondition for receiving and awarding federal construction grants under the Hill-Burton program. At the national level, health planning consisted of ringing pronouncements in preambles to legislation, supported by modest appropriations.
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The 1974 Legislation The Congress held hearings on the planning program early in 1974 and found serious deficiencies in the approach of the federal government. The National Health Planning and Development Act made some important changes in the approach, although there were enough similarities to inspire skepticism.
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It supplanted the Regional Medical Programs, Community Health Planning , Hill-Burton, and the Experimental Health Services Delivery Systems (Cain and Darling, 1979~. The 1974 Act authorized a network of area level agencies (HSAs)
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The SHPDA prepares a preliminary state plan from the Health Systems Plans for approval or disapproval by the Statewide Health Coordinating Council. It serves as the designated planning agency under Section 1122 (capital expenditures review)
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It also reviews budgets and applications of Health Systems Agencies, advises the State Agency on the performance of its functions, and reviews and approves or disapproves state plans and applications for formula grants to the state under a number of federal health programs. National Council on Health Planning and Development The 1974 law created a National Council to advise the Secretary of Health, Education, and Welfare and make recommendations about the development of national health planning policy and the administration of the planning program.
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In 1979, cost containment was explicitly added to the list of national priorities. The 1979 amendments made other changes in the planning program not mentioned elsewhere in this report.
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Policy problems that may be regarded as "external" to the current health planning network, but have an appreciable effect on it, include financing, reimbursement, manpower supply, education and training, and capital supply. Unresolved "internal" policy problems include governance of the health planning agencies, including representation, citizen participation, the role of the consumer, and intergovernmental relations; training of planners and governing body members; establishment of a national limit on the amount of capital expenditures approved in any one year ("capital cap")
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But the planning agencies also are expected to control costs of health care and inhibit the over-use of high cost technology. Many of the achievements asked about or cited for the program typically are concerned with the number of hospital beds allowed, amount of dollars saved, applications rejected, or technology stopped.
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The same study found that equipment and new hospital service proposals were almost always approved (Lewin, 1975; Needleman and Lewin, 1979~. These findings were less surprising when it was also learned that less than half of the agencies believed that capital investment controls were primarily to contain costs and one-fifth of the agencies did not consider cost control as an importrant goal at all.
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Much of the reasoning employed by proponents and critics alike stems from thus far unsupported assumptions about the responses of regulatory agencies and regulated firms to the political context that accompanies imposition of regulatory programs. Until the incentives created by regulatory devices, such as CON programs, are better understood, we will be in the position of legislating in the hope that the public interest is necessarily served by more regulation (Salkever and Bice, 1978~.
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It would be most unfortunate if scholars avoided the more complicated and less satisfying but essential task of understanding and measuring the effects of the planning program. It is the committee's judgment that there is insufficient evidence about planning or capital investment controls under certificate of need to warrant significant changes in the program at this time.
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It is the committee's judgment that the current health planning program has substantial potential for helping to achieve certain important social goals through local planning for improved local health care systems. The committee is concerned about a common tendency to look for evidence of effectiveness too early in social programs, especially when hopes about a program are high.
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But the health planning program is well-suited for determining and expressing the combined health care aspirations of consumers and providers for improving the provision of health care in a given geographic area. The committee recommends that the limitations of HSAs in reducing health care expenditures be recognized, because unrealistic expectations are likely to lead to the conclusion that the program has not succeeded.
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Foremost among the requirements for effecting improvements within fiscal constraints Is a Joint errors Dy providers and pooling their capacities, and making a commitment to adapt resources to help meet those unattended health needs. Resources distribution and organization decisions are best made at a local level and the planning network provides the opportunity and the obligation to address these problems.
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