Voting Behavior of HSA Interest Groups: A Case Study RANDOLPH M. GROSSMAN, MPH
Abstract: A study of the voting behavior of both consumers and providers involved on a Health Systems Agency (HSA) review committee was undertaken to determine the amount of voting cohesion (solidarity) demonstrated by these two basic interest groups as well as the directions in review decisions desired by both of these groups. The case study involved the application of the Rice Index of voting cohesion
behavior to 23 decisions in one of the largest HSAs in the country. The conclusions reached are that: 1) consumers and providers do have differences in their intra-group voting cohesion, but that more importantly 2) they do not appear to be different with respect to the decisions (approve or deny) both groups desire for project reviews. (Am. J. Public Health 68:1191-1194, 1978.)
Introduction
Security Amendments of 1972 and those of certificate-ofneed laws), but potentially by distributing various development grants which currently have not been appropriated. In short, this paradox understates the problem of attempting to utilize pluralist theory as a basis for accomplishing regulatory missions. Indeed, it has been argued rather cogently that the major effect of this legislation will not be to contain resources and resulting costs but to expand them.4'5 Even though there is a large literature on the formation and behavior of interest groups, there remains a dearth of empirical evidence bearing on the germane question of precisely how HSA interest groups develop and the nature of their political behavior. If, for example, the interests of consumers and providers are not demonstrated empirically to be disparate, then the context of competing interests in a political arena for health planning is unwarranted.
It has been argued that Health Systems Agencies (HSAs) as established under P.L. 93-641, the National Health Planning and Resources Development Act of 1974,1 will evolve along competitive multiple interest group lines2 and fragmented autonomous minorities of consumers and providers will emerge. These factions in turn will necessitate the functional approach of continuous reciprocity and logrolling (as in Adam Smith's "hidden hand" model). The rational difficulty with assuming such a pluralistic political environment is that the "you get yours if I get mine" climate is an institutional process which only works well where there are abundant resources.3 Such an environment is predicated upon an economy of abundance sufficient to satisfy many different interests. However, such thinking is contrary to the main objective of P.L. 93-641 which, it can be argued, is both to constrain future resources and to use present ones more efficiently. Thus, the only way to satisfy all of the interest groups involved would be to expand the pie-a costly and undesirable alternative. Yet, P.L. 93-641 gives an HSA many opportunities to increase health resources in its geographic area, not only by recommending approval of the capital expenditures and services (CES) proposals it reviews (e.g., the review section of Section 1122 of the Social
Address reprint requests to Randolph M. Grossman, MPH, Consultant, Chi Systems, Inc., 330 E. Liberty Street, Suite 4A, Ann Arbor, MI 48104. This paper, submitted to the Journal November 11, 1977, was revised and accepted for publication July 18, 1978. AJPH December 1978, Vol. 68, No. 12
Purpose of the Study The principal purpose of the present study is to examine whether there are any differences in the interests of consumers and providers and, if so, to what extent they exist. The voting behavior of consumers and providers on the committee which conducts project reviews in one of the largest HSAs in the country was used to operationalize the concept of self-interest and measure whether or not there is diversity between these two basic interest groups. The purpose here is simply to see if empirical interest groups called "consumers" and "providers" can be discerned in the actual behavior of HSA participants. 1191
GROSSMAN
Case Study Background and Method The present study was undertaken at the Comprehensive Health Planning Council of Southeastern Michigan (CHPC-SEM), located in Detroit, Michigan. This is the third largest HSA (in terms of budget) in the United States. CHPC-SEM has a health service area consisting of seven southeastern counties with a present population of 4.7 million people and an annual operating budget of approximately $2.4 million. There were 31 professional staff members at the time of this study. The Plan Implementation Committee (PIC), which conducts the agency's CES reviews mentioned earlier, had 28 members divided between consumers and providers,* and, like other committees in the agency, it reports to both a Board of Trustees and an Executive Committee, as is required by their committee charges. During the course of the project review process, the PIC will consider the staff analysis, which states whether the proposal is consistent or inconsistent with a number of review criteria adopted by the Board of Trustees, but does not recommend either approval or denial of the project. Board criteria cover five areas: community need, ability to staff and operate, financial feasibility/ cost containment/quality of care, composition of the board of directors of the institution, and consumer participation in the organization under consideration. The PIC makes recommendations on the project to the State Health Planning and Development Agency (SHPDA). For the most part, there is strong agreement between the PIC and Executive Committee in terms of the agency's final recommendation to the SHPDA.** Because of the author's assumption that the PIC review process is the point of greatest interest group impact, the voting behavior of the PIC was chosen for analysis over that of the Executive Committee. This assumption is based on the fact that major debate over a proposal is expected to occur at the level of the PIC, whereas the review process by the Executive Committee is largely a pro forma matter. Over a period covering December 22, 1976 to July 27, 1977 (exluding the month of Januaryt), the votes (approve, disapprove, abstain) of consumers and providers on the PIC were recorded either through a roll call procedure or by a *As of January 20, 1977, the PIC had 13 consumers consisting of three retirees, one housewife, three businesspersons, three labor representatives, and three persons with public sector oriented occupations. The 15 providers on this committee at that time consisted of six physicians, one dentist, one nurse, two PhDs involved in mental health occupations, one social worker, and four persons in administrative occupations. **In terms of hospital reviews completed by both the PIC and the Executive Committee between August 25, 1976, and June 9, 1977, there was a 92.8% (13/14) agreement rate on the recommendation made to the SHPDA. Similarly for nursing homes, there was an 83.3% (5/6) agreement rate for reviews between November 24, 1976, and April 14, 1977, and for CT scanners (considered separately from hospital proposals) reviewed during calendar year 1976, there was a 94.4% (17/18) agreement rate. This is not to imply that strong agreement as shown here means that voting patterns for the two committees will be the same. tData collected by a staff member recording votes did not begin
1192
staff member. In all, 23 substantive reviews were considered. The voting behavior of consumers and providers was assumed to provide an operational measure of the interests of these two groups. For the purpose of this study, the intra-group voting cohesion or solidarity of both consumers and providers as two distinct groups was analyzed using the Rice Index of Cohesion.6-8 This well-known and widely used index was first proposed in the 1920s by the sociologist Stuart A. Rice whose objective was to describe the voting behavior of legislative groups and facilitate the quantitative comparison across voting bodies. Cohesion was defined as ". . . the extent to which the distribution of votes on a legislative roll call deviates from the distribution that would be expected if all influences operated in a random fashion."9 It follows that if 100 votes on an issue were randomly cast, they would be distributed equally on both sides, with 50 yeas and 50 nays. A case such as this would be defined as minimum cohesion and would receive an index value of zero. On the other hand, when all the members of a group vote on the same side of an issue, complete cohesion is considered to have been reached, and an index value of 100 is assigned. Computationally, the Rice Index of Cohesion (RIC) may be defined as follows: RIC = 100lp - (I - p)l where; RIC is expressed as a percentage; and p = the proportion of a group voting "yea" The absolute-value signs insure that the RIC will always be positive. It is possible to modify Rice's Index of Cohesion, to summarize a set of voting issues, by taking the average of the Rice Index scores computed for each issue voted on in the set. For example, if the Rice Index scores for consumers on three ambulatory care issues were 60.4, 90.1, and 83.7, the aggregate RIC score for these as a whole would be: 60.4 + 90.1 + 83.7
3
=78.1
Results RIC scores were calculated for each of the 23 issues involved in this study. These scores were then combined into three groups defined by type of review (hospitals, nursing homes, and Public Health Service grants including related others) using the aggregate method described above. In addition to these grouped cohesion scores for both consumers and providers, Table 1 defines the directionality of whatever level of voting solidarity exists. It should be noted that because the 23 issues analyzed during the seven months of this study were a population of all issues considered by the PIC (during these months), the question of statistically significant differences is irrelevant. If until February of 1977. There were, however, roll call votes at the December 22, 1976, PIC meeting that are included. AJPH December 1978, Vol. 68, No. 12
VOTING OF HSA INTEREST GROUPS TABLE 1-Cohesion and Directionality of Consumers and Providers by Type of Project Review* Project Type
N
RICc
Hospitals Nursing Homes Public Health Service Projects and otherst
6 5
69.3
12
87.8
*N
94.4
RICp
AND
D (5/6) D (3.5/5)
45.8 69.0
D (4/6) D (4/5)
A (10/12
70.0 A (10/12)
A/D
= Number of reviews by project type
RICC = Rice's Index of Cohesion for consumers
RlCp = Rice's Index of Cohension for providers AND = The direction of the cohesion with "A" standing for approvals and "D" standing for disapprovals. Either an "A" or "D" is assigned by determining how a majority of each group voted on the set of projects by type. The numerator of the fraction given in parentheses is the number of issues on which a majority of the group in question voted to approve or disapprove. The denominator is the total number of issues in question. For example, on five of the six hospital proposals, a majority of consumers voted to disapprove. Likewise, on four of the six hospital proposals, a majority of providers voted to disapprove. If on any issue there was not a majority, i.e., a RIC score of zero, one-half of the consumers (or providers) were assigned an "A" and one-half of them were assigned a "D". Hence consumers were evenly divided on one of the five nursing home proposals and therefore half of them were assigned a "D" on that proposal and half were assigned an "A" on it. These fractions are included to give the reader a sense of the strength of directionality for both consumers and providers. tlncludes a voluntary review for Blue Cross/Blue Shield of Michigan and a County Health Department 1122 review.
these data were a sample, then statistical significance should and would have been addressed. The pronounced difference in solidarity levels between consumers and providers voting on hospital issues is not maintained for nursing home issues. Regarding the five nursing home issues displayed in Table 1, we can see that both consumers and providers had relatively high intra-group cohesion and that the direction of this cohesion was again to disapprove projects. Evidence of a difference in cohesion level between consumers and providers is again demonstrated with the twelve Public Health Service and related projects: the RICs are 87.8 per cent and 70.0 per cent, respectively, even though both groups show a tendency to approve this type of proposal. This latter finding (tendency to approve) is interesting because, when one considers the incentive for an HSA's acceptance of federal grant money,16 the result is predictable. The incentive is obvious, albeit ironic in light of the fact that efficiency and cost containment are primary federal objectives: if the HSA declines "free money," the grant is spent in another area, not turned back to the federal government. However, if the objective sought during these issues was increased availability of services rather than cost containment then the results seem more reasonable. The overall conclusion one may draw from this information is that, at least in terms of hospitals and Public Health Service grants, there is evidence that consumers and providers are different with respect to voting solidarity, and consumers appear to exhibit greater solidarity in their voting AJPH December 1978, Vol. 68, No. 12
behavior than do providers. This implies, for example, that a retiree, a banker, and a school teacher may have greater potential for confluence in their health care interests than a group consisting of a physician, a nurse, and a podiatrist. However, the direction of review decisions is the same for both groups. This result is the most important finding of the entire study because, with it, one can argue that the decision of consumers and providers do not appear to be different in terms of the end result desired by both of these two basic interest groups as the theory of interest group liberalism would maintain.tt
Conclusions The results of this case study are in no way definitive, but they imply that HSA decision-making in the area of project review may not be as politically dominated as others have theorized and predicted. More importantly, the analysis points out the need to empirically examine HSA interest group bargaining and the extent to which it exists. To this end it would prove useful to describe more clearly just who potential HSA interest groups are. One method which might be used would be to analyze project review voting behavior through the use of multidimensional scaling techniques such as hierarchical cluster analysis. 10 In this way individual consumers and providers who demonstrate similar voting patterns could be clustered together mathematically as well as described graphically. If the results of this study are upheld by future research, then a more important question will be to explain why consumers and providers involved in HSA project reviews are not confronting one another in a political arena. It may well be the case that as HSAs become more sophisticated in the use of measurable review criteria, they depend less on political solutions and more on rationally-based decisions which should yield greater effectiveness in reaching the goal of increased cost containment. Future research will clarify this relationship. The present study is only an initial step on an intriguing path of questions concerning HSA interest groups.
REFERENCES 1. National Health Planning and Resources Development Act of 1974. P.L. 93-641, 93rd Congress, 2nd Session, January 4, 1975. 2. Vladeck B: Interest group representation and the HSAs: Health planning and political theory. Am J Public Health, 67:23-29, 1977. 3. Dahl RA: A Preface to Democratic Theory, Chicago, London: University of Chicago Press, 1956. 4. Mott B: The New Health Planning System, In Health Services: The Local Perspective, A. Levin (ed.), Proceedings of the American Academy of Political Science, 32:238-254, 1977. 5. Alford R: Health Care Politics. Chicago, London: University of Chicago Press, 1975.
ttStrictly speaking, the theory of interest group liberalism would maintain that consumers and providers are not two basic interest groups but are each composed of a number of separate interest groups. However, it was not the intent of this study to compare other possible interest groups. 1193
GROSSMAN 6. Rice A: Quantitative Methods in Politics. New York: Knopf, 1928, Ch. 6. 7. MacRae D, Jr: Issues and Parties in Legislative Voting: Methods of Statistical Analysis. New York, Evanston, and London: Harper and Row, 1970, 177-179. 8. Anderson L, Watts M, Jr. and Wilcox A: Legislative Roll-Call Analysis. Evanston, IL: Northwestern University Press, 1966, 32-35. 9. Ibid., p 32. 10. Shepard RN, Romney AK and Merlove SB, Eds., Multidimensional Scaling Theory and Applications in the Behavioral
Sciences Vol. I-Theory, New York, San Francisco, London: Seminar Press, 1972.
ACKNOWLEDGMENTS The author would like to acknowledge the assistance of Sheryl Orr of the Comprehensive Health Planning Council of Southeastern Michigan staff for her efforts in data collection, and the perceptive comments of Dr. James Chesney of the University of Michigan as well as those of Dr. Joseph Falkson of the TARP Institute of Washington, DC.
American Men and Women of Science Now in 14th Revision The definitive collection of scientific biographical information, American Men and Women of Science, is now in its 14th revision. The Physical and Biological Sciences Section of the new edition will be published in the fall of 1979 with an estimated 130,000 entries. The National Academy of Sciences is in the process of assembling an advisory committee whose membership will be announced at a later date. Scientists in the physical, biological and mathematical sciences who have been profiled in previous editions of AMWS will receive forms on which to review and revise their entries during the fall and winter of 1978. Those who have moved since preparation of the last edition in 1976 should send address changes to the editors immediately. Nomination of eligible scientists not now included in the directory is invited. There is no charge or obligation to buy involved with listing. Selection is based on attainment of the following criteria: 1) Acheivement, by reason of experience and training, of a stature in scientific work equivalent to that associated with the doctoral degree, coupled with presently continued activity in such work; or 2) Research activity of high quality in science as evidenced by publication in reputable scientific journals; or, for those whose work cannot be published because of governmental or industrial security, research activity of high quality in science as evidenced by the judgment of the individual's peers; or 3) Attainment of a position of substantial responsiblity requiring scientific training and experience to the extent described for (1) and (2). Send nominations and address changes to The Editors, American Men and Women of Science, PO Box 25001, Tempe, AZ 85282. The Jaques Cattell Press of Tempe, Arizona will continue to edit the directory which will be published by the R. R. Bowker Company of New York (a Xerox Publishing Company) under the Bowker/Cattell imprint. American Men and Women of Science 14th Edition 7 Volume A-Z plus Indexes volume $365.00/300.00 pre-publication price $37.50 per volume
1194
AJPH December 1978, Vol. 68, No. 12
Abstract: A study of the voting behavior of both consumers and providers involved on a Health Systems Agency (HSA) review committee was undertaken to determine the amount of voting cohesion (solidarity) demonstrated by these two basic interest groups as well as the directions in review decisions desired by both of these groups. The case study involved the application of the Rice Index of voting cohesion
behavior to 23 decisions in one of the largest HSAs in the country. The conclusions reached are that: 1) consumers and providers do have differences in their intra-group voting cohesion, but that more importantly 2) they do not appear to be different with respect to the decisions (approve or deny) both groups desire for project reviews. (Am. J. Public Health 68:1191-1194, 1978.)
Introduction
Security Amendments of 1972 and those of certificate-ofneed laws), but potentially by distributing various development grants which currently have not been appropriated. In short, this paradox understates the problem of attempting to utilize pluralist theory as a basis for accomplishing regulatory missions. Indeed, it has been argued rather cogently that the major effect of this legislation will not be to contain resources and resulting costs but to expand them.4'5 Even though there is a large literature on the formation and behavior of interest groups, there remains a dearth of empirical evidence bearing on the germane question of precisely how HSA interest groups develop and the nature of their political behavior. If, for example, the interests of consumers and providers are not demonstrated empirically to be disparate, then the context of competing interests in a political arena for health planning is unwarranted.
It has been argued that Health Systems Agencies (HSAs) as established under P.L. 93-641, the National Health Planning and Resources Development Act of 1974,1 will evolve along competitive multiple interest group lines2 and fragmented autonomous minorities of consumers and providers will emerge. These factions in turn will necessitate the functional approach of continuous reciprocity and logrolling (as in Adam Smith's "hidden hand" model). The rational difficulty with assuming such a pluralistic political environment is that the "you get yours if I get mine" climate is an institutional process which only works well where there are abundant resources.3 Such an environment is predicated upon an economy of abundance sufficient to satisfy many different interests. However, such thinking is contrary to the main objective of P.L. 93-641 which, it can be argued, is both to constrain future resources and to use present ones more efficiently. Thus, the only way to satisfy all of the interest groups involved would be to expand the pie-a costly and undesirable alternative. Yet, P.L. 93-641 gives an HSA many opportunities to increase health resources in its geographic area, not only by recommending approval of the capital expenditures and services (CES) proposals it reviews (e.g., the review section of Section 1122 of the Social
Address reprint requests to Randolph M. Grossman, MPH, Consultant, Chi Systems, Inc., 330 E. Liberty Street, Suite 4A, Ann Arbor, MI 48104. This paper, submitted to the Journal November 11, 1977, was revised and accepted for publication July 18, 1978. AJPH December 1978, Vol. 68, No. 12
Purpose of the Study The principal purpose of the present study is to examine whether there are any differences in the interests of consumers and providers and, if so, to what extent they exist. The voting behavior of consumers and providers on the committee which conducts project reviews in one of the largest HSAs in the country was used to operationalize the concept of self-interest and measure whether or not there is diversity between these two basic interest groups. The purpose here is simply to see if empirical interest groups called "consumers" and "providers" can be discerned in the actual behavior of HSA participants. 1191
GROSSMAN
Case Study Background and Method The present study was undertaken at the Comprehensive Health Planning Council of Southeastern Michigan (CHPC-SEM), located in Detroit, Michigan. This is the third largest HSA (in terms of budget) in the United States. CHPC-SEM has a health service area consisting of seven southeastern counties with a present population of 4.7 million people and an annual operating budget of approximately $2.4 million. There were 31 professional staff members at the time of this study. The Plan Implementation Committee (PIC), which conducts the agency's CES reviews mentioned earlier, had 28 members divided between consumers and providers,* and, like other committees in the agency, it reports to both a Board of Trustees and an Executive Committee, as is required by their committee charges. During the course of the project review process, the PIC will consider the staff analysis, which states whether the proposal is consistent or inconsistent with a number of review criteria adopted by the Board of Trustees, but does not recommend either approval or denial of the project. Board criteria cover five areas: community need, ability to staff and operate, financial feasibility/ cost containment/quality of care, composition of the board of directors of the institution, and consumer participation in the organization under consideration. The PIC makes recommendations on the project to the State Health Planning and Development Agency (SHPDA). For the most part, there is strong agreement between the PIC and Executive Committee in terms of the agency's final recommendation to the SHPDA.** Because of the author's assumption that the PIC review process is the point of greatest interest group impact, the voting behavior of the PIC was chosen for analysis over that of the Executive Committee. This assumption is based on the fact that major debate over a proposal is expected to occur at the level of the PIC, whereas the review process by the Executive Committee is largely a pro forma matter. Over a period covering December 22, 1976 to July 27, 1977 (exluding the month of Januaryt), the votes (approve, disapprove, abstain) of consumers and providers on the PIC were recorded either through a roll call procedure or by a *As of January 20, 1977, the PIC had 13 consumers consisting of three retirees, one housewife, three businesspersons, three labor representatives, and three persons with public sector oriented occupations. The 15 providers on this committee at that time consisted of six physicians, one dentist, one nurse, two PhDs involved in mental health occupations, one social worker, and four persons in administrative occupations. **In terms of hospital reviews completed by both the PIC and the Executive Committee between August 25, 1976, and June 9, 1977, there was a 92.8% (13/14) agreement rate on the recommendation made to the SHPDA. Similarly for nursing homes, there was an 83.3% (5/6) agreement rate for reviews between November 24, 1976, and April 14, 1977, and for CT scanners (considered separately from hospital proposals) reviewed during calendar year 1976, there was a 94.4% (17/18) agreement rate. This is not to imply that strong agreement as shown here means that voting patterns for the two committees will be the same. tData collected by a staff member recording votes did not begin
1192
staff member. In all, 23 substantive reviews were considered. The voting behavior of consumers and providers was assumed to provide an operational measure of the interests of these two groups. For the purpose of this study, the intra-group voting cohesion or solidarity of both consumers and providers as two distinct groups was analyzed using the Rice Index of Cohesion.6-8 This well-known and widely used index was first proposed in the 1920s by the sociologist Stuart A. Rice whose objective was to describe the voting behavior of legislative groups and facilitate the quantitative comparison across voting bodies. Cohesion was defined as ". . . the extent to which the distribution of votes on a legislative roll call deviates from the distribution that would be expected if all influences operated in a random fashion."9 It follows that if 100 votes on an issue were randomly cast, they would be distributed equally on both sides, with 50 yeas and 50 nays. A case such as this would be defined as minimum cohesion and would receive an index value of zero. On the other hand, when all the members of a group vote on the same side of an issue, complete cohesion is considered to have been reached, and an index value of 100 is assigned. Computationally, the Rice Index of Cohesion (RIC) may be defined as follows: RIC = 100lp - (I - p)l where; RIC is expressed as a percentage; and p = the proportion of a group voting "yea" The absolute-value signs insure that the RIC will always be positive. It is possible to modify Rice's Index of Cohesion, to summarize a set of voting issues, by taking the average of the Rice Index scores computed for each issue voted on in the set. For example, if the Rice Index scores for consumers on three ambulatory care issues were 60.4, 90.1, and 83.7, the aggregate RIC score for these as a whole would be: 60.4 + 90.1 + 83.7
3
=78.1
Results RIC scores were calculated for each of the 23 issues involved in this study. These scores were then combined into three groups defined by type of review (hospitals, nursing homes, and Public Health Service grants including related others) using the aggregate method described above. In addition to these grouped cohesion scores for both consumers and providers, Table 1 defines the directionality of whatever level of voting solidarity exists. It should be noted that because the 23 issues analyzed during the seven months of this study were a population of all issues considered by the PIC (during these months), the question of statistically significant differences is irrelevant. If until February of 1977. There were, however, roll call votes at the December 22, 1976, PIC meeting that are included. AJPH December 1978, Vol. 68, No. 12
VOTING OF HSA INTEREST GROUPS TABLE 1-Cohesion and Directionality of Consumers and Providers by Type of Project Review* Project Type
N
RICc
Hospitals Nursing Homes Public Health Service Projects and otherst
6 5
69.3
12
87.8
*N
94.4
RICp
AND
D (5/6) D (3.5/5)
45.8 69.0
D (4/6) D (4/5)
A (10/12
70.0 A (10/12)
A/D
= Number of reviews by project type
RICC = Rice's Index of Cohesion for consumers
RlCp = Rice's Index of Cohension for providers AND = The direction of the cohesion with "A" standing for approvals and "D" standing for disapprovals. Either an "A" or "D" is assigned by determining how a majority of each group voted on the set of projects by type. The numerator of the fraction given in parentheses is the number of issues on which a majority of the group in question voted to approve or disapprove. The denominator is the total number of issues in question. For example, on five of the six hospital proposals, a majority of consumers voted to disapprove. Likewise, on four of the six hospital proposals, a majority of providers voted to disapprove. If on any issue there was not a majority, i.e., a RIC score of zero, one-half of the consumers (or providers) were assigned an "A" and one-half of them were assigned a "D". Hence consumers were evenly divided on one of the five nursing home proposals and therefore half of them were assigned a "D" on that proposal and half were assigned an "A" on it. These fractions are included to give the reader a sense of the strength of directionality for both consumers and providers. tlncludes a voluntary review for Blue Cross/Blue Shield of Michigan and a County Health Department 1122 review.
these data were a sample, then statistical significance should and would have been addressed. The pronounced difference in solidarity levels between consumers and providers voting on hospital issues is not maintained for nursing home issues. Regarding the five nursing home issues displayed in Table 1, we can see that both consumers and providers had relatively high intra-group cohesion and that the direction of this cohesion was again to disapprove projects. Evidence of a difference in cohesion level between consumers and providers is again demonstrated with the twelve Public Health Service and related projects: the RICs are 87.8 per cent and 70.0 per cent, respectively, even though both groups show a tendency to approve this type of proposal. This latter finding (tendency to approve) is interesting because, when one considers the incentive for an HSA's acceptance of federal grant money,16 the result is predictable. The incentive is obvious, albeit ironic in light of the fact that efficiency and cost containment are primary federal objectives: if the HSA declines "free money," the grant is spent in another area, not turned back to the federal government. However, if the objective sought during these issues was increased availability of services rather than cost containment then the results seem more reasonable. The overall conclusion one may draw from this information is that, at least in terms of hospitals and Public Health Service grants, there is evidence that consumers and providers are different with respect to voting solidarity, and consumers appear to exhibit greater solidarity in their voting AJPH December 1978, Vol. 68, No. 12
behavior than do providers. This implies, for example, that a retiree, a banker, and a school teacher may have greater potential for confluence in their health care interests than a group consisting of a physician, a nurse, and a podiatrist. However, the direction of review decisions is the same for both groups. This result is the most important finding of the entire study because, with it, one can argue that the decision of consumers and providers do not appear to be different in terms of the end result desired by both of these two basic interest groups as the theory of interest group liberalism would maintain.tt
Conclusions The results of this case study are in no way definitive, but they imply that HSA decision-making in the area of project review may not be as politically dominated as others have theorized and predicted. More importantly, the analysis points out the need to empirically examine HSA interest group bargaining and the extent to which it exists. To this end it would prove useful to describe more clearly just who potential HSA interest groups are. One method which might be used would be to analyze project review voting behavior through the use of multidimensional scaling techniques such as hierarchical cluster analysis. 10 In this way individual consumers and providers who demonstrate similar voting patterns could be clustered together mathematically as well as described graphically. If the results of this study are upheld by future research, then a more important question will be to explain why consumers and providers involved in HSA project reviews are not confronting one another in a political arena. It may well be the case that as HSAs become more sophisticated in the use of measurable review criteria, they depend less on political solutions and more on rationally-based decisions which should yield greater effectiveness in reaching the goal of increased cost containment. Future research will clarify this relationship. The present study is only an initial step on an intriguing path of questions concerning HSA interest groups.
REFERENCES 1. National Health Planning and Resources Development Act of 1974. P.L. 93-641, 93rd Congress, 2nd Session, January 4, 1975. 2. Vladeck B: Interest group representation and the HSAs: Health planning and political theory. Am J Public Health, 67:23-29, 1977. 3. Dahl RA: A Preface to Democratic Theory, Chicago, London: University of Chicago Press, 1956. 4. Mott B: The New Health Planning System, In Health Services: The Local Perspective, A. Levin (ed.), Proceedings of the American Academy of Political Science, 32:238-254, 1977. 5. Alford R: Health Care Politics. Chicago, London: University of Chicago Press, 1975.
ttStrictly speaking, the theory of interest group liberalism would maintain that consumers and providers are not two basic interest groups but are each composed of a number of separate interest groups. However, it was not the intent of this study to compare other possible interest groups. 1193
GROSSMAN 6. Rice A: Quantitative Methods in Politics. New York: Knopf, 1928, Ch. 6. 7. MacRae D, Jr: Issues and Parties in Legislative Voting: Methods of Statistical Analysis. New York, Evanston, and London: Harper and Row, 1970, 177-179. 8. Anderson L, Watts M, Jr. and Wilcox A: Legislative Roll-Call Analysis. Evanston, IL: Northwestern University Press, 1966, 32-35. 9. Ibid., p 32. 10. Shepard RN, Romney AK and Merlove SB, Eds., Multidimensional Scaling Theory and Applications in the Behavioral
Sciences Vol. I-Theory, New York, San Francisco, London: Seminar Press, 1972.
ACKNOWLEDGMENTS The author would like to acknowledge the assistance of Sheryl Orr of the Comprehensive Health Planning Council of Southeastern Michigan staff for her efforts in data collection, and the perceptive comments of Dr. James Chesney of the University of Michigan as well as those of Dr. Joseph Falkson of the TARP Institute of Washington, DC.
American Men and Women of Science Now in 14th Revision The definitive collection of scientific biographical information, American Men and Women of Science, is now in its 14th revision. The Physical and Biological Sciences Section of the new edition will be published in the fall of 1979 with an estimated 130,000 entries. The National Academy of Sciences is in the process of assembling an advisory committee whose membership will be announced at a later date. Scientists in the physical, biological and mathematical sciences who have been profiled in previous editions of AMWS will receive forms on which to review and revise their entries during the fall and winter of 1978. Those who have moved since preparation of the last edition in 1976 should send address changes to the editors immediately. Nomination of eligible scientists not now included in the directory is invited. There is no charge or obligation to buy involved with listing. Selection is based on attainment of the following criteria: 1) Acheivement, by reason of experience and training, of a stature in scientific work equivalent to that associated with the doctoral degree, coupled with presently continued activity in such work; or 2) Research activity of high quality in science as evidenced by publication in reputable scientific journals; or, for those whose work cannot be published because of governmental or industrial security, research activity of high quality in science as evidenced by the judgment of the individual's peers; or 3) Attainment of a position of substantial responsiblity requiring scientific training and experience to the extent described for (1) and (2). Send nominations and address changes to The Editors, American Men and Women of Science, PO Box 25001, Tempe, AZ 85282. The Jaques Cattell Press of Tempe, Arizona will continue to edit the directory which will be published by the R. R. Bowker Company of New York (a Xerox Publishing Company) under the Bowker/Cattell imprint. American Men and Women of Science 14th Edition 7 Volume A-Z plus Indexes volume $365.00/300.00 pre-publication price $37.50 per volume
1194
AJPH December 1978, Vol. 68, No. 12
