EDITORIALS I. Broad acceptance of a regional approach to health ca(re delisvery. This implies support by the puiblic. government, and providers for coordinating goals and services for different levels of care within a geographic region. Coordination in turn implies the need for a central decision-making body. and for giving up of a certain degree of local or individual autonomy. 2. Existence of an effective decision *naking organization. This predicates legitimacy and authority. which are based not only on law. but also on aicceptance by the preponderance of people and agencies who ire aiffected. This is generated by demonstration of administrative. political. and technical competence. 3. Lintkages it'itli ollte level-vs oj governnent hIzici,l enis.r(e coordination of health goals. These are important in ouI system since regulation and utinding-both essential to the implementation of plans-are the functions of other agencies. namely. the State and Federal Governments. It would seem in the cases cited. the last named charac-
Address reprint requests to Professor Harry T. Phillips. Department of Health Administration. School of Public Health. University of North Carolina. Chapel Hill. NC 27514.
teristic was deficient. What can be done to reduce the hazard of the regional planning agencies (HSAs) being overridden frequently by other authorities such as the State Health Planning and Development Agencies (SHPDAs) and the State Health Coordinating Councils (SHCCs) as laid out in P.L. 93-641. or by the Secretary of Health. Education. and Welfare? Here are a few suggestions. Standards. criteria. and guidelines for making decision should be as clear and objective as possible. All parties concerned-no matter whom they represent-applicants. HSAs. SHPDAs. SHCCs. and DHEW should be aware of the rules of the game beforehand. And all parties should be encouraiged to communicate with each other openly and freely bejore the decision is handed down. In health planning. compromises are sometimes necessary. and it is good practice to listen. talk. negotiate. and resolve conflicts before announcing a decision.
HARRY T. PHILLIPS, MD, DPH REFERENCE 1. Mott, P. D., et al. Difficult issues in health planning. development. and review. Am. J. Public Health 66:744-746. 1976.
Boundary Lines and the People's Health In the 1960's there were many advocates for greater involvement of citizens in health planning and decision-making at the community and neighborhood levels. This was seen as an answer to the problems which continued to plague the system in spite of relative affluence and technological advance. There were a number of efforts to increase federal program effectiveness by setting up substate districts. All of them required the empiric definition of a geographic area whose population and characteristics would invite the participation of local citizens in decision-making. An article by John Hammond in the current issue of the Journal delineates the boundaries of the most recent of these efforts. ' The ""grass roots" or ""bottom-up" philosophy is embodied again in the National Health Planning and Resources Development Act of 1974. The most important aim of the Act, stated as a priority of the federal government, is the achievement of equal access to quality health care at a reasonable cost. The Act places the Health Systems Agency, a substate district, (although in a few cases the state is the district) in a primal position. All prescribed functions for the health care system are initiated at the area level, and different ones are routed by different paths to the state agency. the Statewide Health Coordinating Council (SHCC). and the federal departments. For example, the certificate-of-need function ends up at the state agency level and potentially in the state courts. The health systems plans go through the state agency to the SHCC for processing and adoption within the 738
state plan. Other activities. such as the annual implementation plans. go directly to the SHCC unless the latter wants state agency input. There are provisions for technical assistance to the HSAs from both federal and state sources as well as for the preparation of guidelines by the Secretary of Health. Education, and Welfare and the definition of statewide issues by the state agency. but the law still puts its emphasis on the HSA to develop the plans and to see to their implementation. For all who believe that this is the correct organizational pattern, the recognition and analysis of several major elements in the process may help maximize its chances for success: 1. The planning process should start with policy and priority setting in conformance with guidelines and analysis of the local data base. The judgments involved, however, are value judgments based on perceptions of the meaning of ''equal" in equal access and ""reasonable" in reasonable costs. 2. The plans should be based upon the selection. from among several alternatives. of those that the board perceives to best fit its policies and priorities. 3. The process should allow for provider participation. but consumer majority is required to get a relevant "'grass roots" value judgment. 4. The original bills called for private not-for-profit corporations as the area agencies, but the final compromise was that, under certain conditions, local government and public
AJPH August, 1976, Vol. 66, No. 8
EDITORIALS
regional planning bodies would be eligible if they organi7ed the appropriate governing body, a consumer majority being mandatory. The effect of this pluralism in key local units on the ability of these units to fuinction in a coordinated system within state or country remains unknown. Since the thrust of the law is heavily weighted toward cost containment through the use of regulatory controls, it will be extremely important to protect the individual decision-making caipaibility of the boards by freeing them of potential charges of conflict of interest. This is best done by assuring that the decisions are made as objectively as possible by consumers who have been carefully picked to actually represent the strata of consumers in the community. Part of the process should be to give the consumers on the boards sufficient visibility so that they will be accountable to the public at large and. in turn. be in a position to expect public support should they be threatened by paternalistic. elitist. or local. state. or federal governmental domination. The law itself reflects the fact that it is the product of a committee working for political compromise. However, its implementaition will require clarification of the ambiguiities which reflect the compromise. The Health Systems Agency must assuire that c ontsuemers make the value judgments needed to reconcile the costs of improving access to health services for the underserved. while. at the same time. (based upon provider definitions of "'quality" and "health") they set an aiffordable level of aictivity to best serve their constituency in the community. 'I'his is a large order to fill. Agency staff will have a tremendous responsibility preparing working documents that are objective interpretations of the data base and that outline as many alternaitives as possible. Alternatives can be developed around the inevitable differences between the best opinions of different classes of providers. and different professional groups. both technical and huimanistic. Provisions of the law also reflect the other purposes and organizaitional patterns thait were in the minds of' some of those who developed it: that the local agency function as a provider-dominated board. with consuimers assigned to the role of interpreting the board's aictions to the community: that ultimate accountability be the responsibility of local government: that the agency be an outreach arm of the federal government. If Health Systems Agencies follow any one of these lines. true consumerism will never be tested. It has been stated that the Health Planning and Resources Development Act of 1974 may be the final attempt to test whether a consumer-gujided management system can be effective and achieve the aims of the nation as expressed by the Congress. If the aim of HSAs is the achievement of equal access to quality health care at reasonable cost. it
AJPH August, 1976, Vol. 66, No. 8
would have been wise to have related the designation of geographic areas to this aim. Hammond's concern over the inability to get congruent boundaries under various authorities reflects the laick of any clear definition of the model for plainning to be pursued. In the area designation process there was from the beginning no real evidence as to what popuilation size wouild favor which type of organizational pattern. A range from 500.000 to 3,000.000. six-fold. certainly is too broad to expect uniform results in defining representation of elements in the community based upon socioeconomic status, age. ethnic, or other stratifications. The concept of SMSA* wide planning clearly directs the process away from truie local planning. If the unique elements in the data base are to be the key to planning within the framework of federal guidelines supplemented by statewide positions. those in the ghettos are not apt to be well handled simultaneously with those of an affluent suburban community. Even though the law still insists on a consumer majority. many of the principal provisions are designed to minimize its impaict. Many of us would put our trust in the collective wisdom of the people. properly chosen to be a true sample of the area's demographic patterns. to select the best balances between health care and care of the pocketbook. It becomes our responsibility to protect the process more actively. It is. after all, the citizens' health. and the care of the citizens' money with which the law is concerned. It is the citizens who must make the valuie judgments.
MARK H. LEPPER. MD REFERENCE 1. Hammond. J. R. Substate district. HSA. and PSRO area designations. Am. J. Public Health 66:788-790. 1976.
Address repnint requests to Dr. Mark H. Lepper. Vice President for Evaluation. Rush-Presbyterian-St. Luke's Medical Center. 1753 West Congress Parkway. Chicago. IL 60612.
*Standaird Metropolitain Statisticail Areas
Ekditor's Note: As tihis is wvrittenn-in eaJrl June-we are receiving re(actions to a(n editorial bh Dr. Anthony Robbins which appeared in May and also dealt wit/i P.l.. 93-M41. It is obvious that there are mna!q very diflirent views of thi.s ies lawv, atnd tha(t where
a person sits is related to the viewt he sees. Tws o different viewpoints expressed above relate to articles published in this issue. Other opinions wiill be exposed in ensuin,g issues of the Journal.
739
Address reprint requests to Professor Harry T. Phillips. Department of Health Administration. School of Public Health. University of North Carolina. Chapel Hill. NC 27514.
teristic was deficient. What can be done to reduce the hazard of the regional planning agencies (HSAs) being overridden frequently by other authorities such as the State Health Planning and Development Agencies (SHPDAs) and the State Health Coordinating Councils (SHCCs) as laid out in P.L. 93-641. or by the Secretary of Health. Education. and Welfare? Here are a few suggestions. Standards. criteria. and guidelines for making decision should be as clear and objective as possible. All parties concerned-no matter whom they represent-applicants. HSAs. SHPDAs. SHCCs. and DHEW should be aware of the rules of the game beforehand. And all parties should be encouraiged to communicate with each other openly and freely bejore the decision is handed down. In health planning. compromises are sometimes necessary. and it is good practice to listen. talk. negotiate. and resolve conflicts before announcing a decision.
HARRY T. PHILLIPS, MD, DPH REFERENCE 1. Mott, P. D., et al. Difficult issues in health planning. development. and review. Am. J. Public Health 66:744-746. 1976.
Boundary Lines and the People's Health In the 1960's there were many advocates for greater involvement of citizens in health planning and decision-making at the community and neighborhood levels. This was seen as an answer to the problems which continued to plague the system in spite of relative affluence and technological advance. There were a number of efforts to increase federal program effectiveness by setting up substate districts. All of them required the empiric definition of a geographic area whose population and characteristics would invite the participation of local citizens in decision-making. An article by John Hammond in the current issue of the Journal delineates the boundaries of the most recent of these efforts. ' The ""grass roots" or ""bottom-up" philosophy is embodied again in the National Health Planning and Resources Development Act of 1974. The most important aim of the Act, stated as a priority of the federal government, is the achievement of equal access to quality health care at a reasonable cost. The Act places the Health Systems Agency, a substate district, (although in a few cases the state is the district) in a primal position. All prescribed functions for the health care system are initiated at the area level, and different ones are routed by different paths to the state agency. the Statewide Health Coordinating Council (SHCC). and the federal departments. For example, the certificate-of-need function ends up at the state agency level and potentially in the state courts. The health systems plans go through the state agency to the SHCC for processing and adoption within the 738
state plan. Other activities. such as the annual implementation plans. go directly to the SHCC unless the latter wants state agency input. There are provisions for technical assistance to the HSAs from both federal and state sources as well as for the preparation of guidelines by the Secretary of Health. Education, and Welfare and the definition of statewide issues by the state agency. but the law still puts its emphasis on the HSA to develop the plans and to see to their implementation. For all who believe that this is the correct organizational pattern, the recognition and analysis of several major elements in the process may help maximize its chances for success: 1. The planning process should start with policy and priority setting in conformance with guidelines and analysis of the local data base. The judgments involved, however, are value judgments based on perceptions of the meaning of ''equal" in equal access and ""reasonable" in reasonable costs. 2. The plans should be based upon the selection. from among several alternatives. of those that the board perceives to best fit its policies and priorities. 3. The process should allow for provider participation. but consumer majority is required to get a relevant "'grass roots" value judgment. 4. The original bills called for private not-for-profit corporations as the area agencies, but the final compromise was that, under certain conditions, local government and public
AJPH August, 1976, Vol. 66, No. 8
EDITORIALS
regional planning bodies would be eligible if they organi7ed the appropriate governing body, a consumer majority being mandatory. The effect of this pluralism in key local units on the ability of these units to fuinction in a coordinated system within state or country remains unknown. Since the thrust of the law is heavily weighted toward cost containment through the use of regulatory controls, it will be extremely important to protect the individual decision-making caipaibility of the boards by freeing them of potential charges of conflict of interest. This is best done by assuring that the decisions are made as objectively as possible by consumers who have been carefully picked to actually represent the strata of consumers in the community. Part of the process should be to give the consumers on the boards sufficient visibility so that they will be accountable to the public at large and. in turn. be in a position to expect public support should they be threatened by paternalistic. elitist. or local. state. or federal governmental domination. The law itself reflects the fact that it is the product of a committee working for political compromise. However, its implementaition will require clarification of the ambiguiities which reflect the compromise. The Health Systems Agency must assuire that c ontsuemers make the value judgments needed to reconcile the costs of improving access to health services for the underserved. while. at the same time. (based upon provider definitions of "'quality" and "health") they set an aiffordable level of aictivity to best serve their constituency in the community. 'I'his is a large order to fill. Agency staff will have a tremendous responsibility preparing working documents that are objective interpretations of the data base and that outline as many alternaitives as possible. Alternatives can be developed around the inevitable differences between the best opinions of different classes of providers. and different professional groups. both technical and huimanistic. Provisions of the law also reflect the other purposes and organizaitional patterns thait were in the minds of' some of those who developed it: that the local agency function as a provider-dominated board. with consuimers assigned to the role of interpreting the board's aictions to the community: that ultimate accountability be the responsibility of local government: that the agency be an outreach arm of the federal government. If Health Systems Agencies follow any one of these lines. true consumerism will never be tested. It has been stated that the Health Planning and Resources Development Act of 1974 may be the final attempt to test whether a consumer-gujided management system can be effective and achieve the aims of the nation as expressed by the Congress. If the aim of HSAs is the achievement of equal access to quality health care at reasonable cost. it
AJPH August, 1976, Vol. 66, No. 8
would have been wise to have related the designation of geographic areas to this aim. Hammond's concern over the inability to get congruent boundaries under various authorities reflects the laick of any clear definition of the model for plainning to be pursued. In the area designation process there was from the beginning no real evidence as to what popuilation size wouild favor which type of organizational pattern. A range from 500.000 to 3,000.000. six-fold. certainly is too broad to expect uniform results in defining representation of elements in the community based upon socioeconomic status, age. ethnic, or other stratifications. The concept of SMSA* wide planning clearly directs the process away from truie local planning. If the unique elements in the data base are to be the key to planning within the framework of federal guidelines supplemented by statewide positions. those in the ghettos are not apt to be well handled simultaneously with those of an affluent suburban community. Even though the law still insists on a consumer majority. many of the principal provisions are designed to minimize its impaict. Many of us would put our trust in the collective wisdom of the people. properly chosen to be a true sample of the area's demographic patterns. to select the best balances between health care and care of the pocketbook. It becomes our responsibility to protect the process more actively. It is. after all, the citizens' health. and the care of the citizens' money with which the law is concerned. It is the citizens who must make the valuie judgments.
MARK H. LEPPER. MD REFERENCE 1. Hammond. J. R. Substate district. HSA. and PSRO area designations. Am. J. Public Health 66:788-790. 1976.
Address repnint requests to Dr. Mark H. Lepper. Vice President for Evaluation. Rush-Presbyterian-St. Luke's Medical Center. 1753 West Congress Parkway. Chicago. IL 60612.
*Standaird Metropolitain Statisticail Areas
Ekditor's Note: As tihis is wvrittenn-in eaJrl June-we are receiving re(actions to a(n editorial bh Dr. Anthony Robbins which appeared in May and also dealt wit/i P.l.. 93-M41. It is obvious that there are mna!q very diflirent views of thi.s ies lawv, atnd tha(t where
a person sits is related to the viewt he sees. Tws o different viewpoints expressed above relate to articles published in this issue. Other opinions wiill be exposed in ensuin,g issues of the Journal.
739
