Health Goals And Health Indicators

Policy, Planning, And Evaluation

Jack Elinson

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429727283
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

This volume brings together the perspectives and expertise of both medical and social sciences. The major topics include criteria for the determination of health goals, the analysis of health policies, and the indicators of health status that may he used to judge the consequences of health practices and policies. Unmet health care needs, current national health policy and local planning, health data for policy and planning, and future directions in national health policy are also examined. These issues are then considered in light of the readiness of the sociomedical sciences to measure health status. Contributors discuss the behavioral measurement of health status, the measurement of psychological well-being, the assessment of dental health needs, and the possible impact of recently developed sociomedical health indicators on health policy.

1
Health Planning in The United States: Where We Stand Today

Harry P. Cain II and Helen Ν. Thornberry

Health Planning in the United States: Where We Stand Today

The purposes of this paper are to report on where we stand today (January 20, 1977) in the implementation of a national health planning program and to briefly,discuss our most serious challenges and problems. As background, the history and highlights of the legislation under which the program operates are given.

The National Health Planning and Resources Development Act (Public Law 93-641) was passed in January 1975. After many months of hearings and debates, the Congress concluded that previous attempts to plan for health services and develop resources in a rational manner had not been successful, although there were some notable achievements within programs such as the Regional Medical Program, Hill-Burton and Comprehensive Health Planning, the progenitors of this legislation. The Congress found that there was an urgent need to restructure and strengthen areawide and State planning for health services, manpower and facilities. It was also evident that a national health planning policy which could provide guidance for the development of resources throughout the nation (especially medical facilities and new technology) and assistance in setting priorities for Federal programs and investments was required. In the absence of clear national goals and guidelines (and internally consistent Federal policies,) programs aimed at improving the system had been fragmented and uncoordinated continuing or exacerbating existing problems of maldistribution and spiraling costs. As summarized in the Act, inadequate incentives to use appropriate levels of care and for the substitution of ambulatory, intermediate and home health care all less expensive than inpatient care were found to have contributed to the cost spiral. The massive infusion of Federal funds in the 1960's into the existing system—with no cost containment incentives, indeed with a number of cost inflating pressures—contributed to the increases, and yet failed to produce an adequate supply or distribution of health resources for all parts of the country. Much of this growth stemmed from the cost escalating character of the system. For example, for institutions there is cost based, retrospective, third-party reimbursement for services rendered.

In general, It was evident in 1974 during the hearings, that in some places in the nation, and for some services in a number of locations, and for some sub-populations, there were still serious problems of access to health care, quality of care, and the availability of services, as well as instances in which all citizens have not shared fully in the benefits of social and medical progress in this century, and in this legislation the Congress reaffirmed the nation's commitment to quality health care as needed by all citizens. However, it was manifest that the most serious problems confronting the nation as a whole related to the burgeoning costs of care and the seemingly endless possibilities for care which stem from the technological and biomedical discoveries in the past 10-20 years.

It is these latter two forces—cost increases and technological advances—coupled with the changing age distribution of the population and the growth in the number of elderly with their higher service needs, and the shift from the predominance of acute and infectious conditions to chronic health problems which have spotlighted a need for, and triggered widespread interest in, improved health planning and resources distribution in this nation. As the total costs of health care and the proportion of the nation's resources committed to health services expand there has been, concomitantly, an emerging sensitivity to the finiteness of our resources.

Put another way, there is a new awareness that the simpler questions about financing and planning for new services and programs—the issues of the 50's and 60's— which themselves have not been resolved completely—have been replaced by the far more complex and threatening questions concerning allocation of scarce resources in the face of large and growing demands for services. To complicate matters, health services, health, and quality of life are all some of the most salient and emotional issues for any nation or community. Further, in the health industry, as the second largest employer of service workers (over 4.7 million persons) the issues related to jobs at a time of high unemployment have surfaced as factors which cannot be ignored. These issues can be especially critical at the local level.

Recent figures on national health expenditures illustrate the seriousness of the cost problem. In 1960, the total national investment in health care was 25 billion dollars, $142 per capita, or 5.2% of the Gross National Product. By 1970, the total investment had climbed to 69 billion dollars, or $334 per capita, (nearly twice as much), and 7.2% of the GNP. For 1976, the total investment had doubled again to 139 billion dollars and more than 8.5% of the Gross National Product. Current projections for 1981 are for 264.3 billion dollars, $1159 per capita and a startling 10.2% of the Gross National Product.

Presumably, the alarm with which these rapidly growing investments are viewed would be tempered if they were clearly purchasing improved health, more effective distribution of diagnostic, curing and caring services, and eliminating inequities in the system. Certainly some progress has been made. For example, the traditional disparities in health status and health services utilization by income and minority group status have been narrowed, and for some conditions, the death rates have declined.

However, the improvements in the system have apparently been small, compared to the size of the increases in the investment (1) and for some, such as the elderly, the actual out of pocket expenditures over the same time periods have increased, a problem for the elderly which was to have been ameliorated by Medicare. Moreover, special programs such as Medicaid, Maternal and Child Health, Women, Infant, and Child Feeding and Nutrition, Community Mental Health Centers, etc. have been seriously threatened by the government's liability to absorb the escalating costs of maintaining the most essential (and legally required) programs. There is also no way to know how many needed programs were never initiated because established programs were struggling to survive the budgeting process.

These higher costs have not only drained the public purse, but in the private sector have been translated into dramatic increases in the premiums paid for employees by business, industry and labor. For example, the President of General Motors reported that GM spent more for health insurance coverage in 1975 than it did for steel-·—and that is not meant to comment on the amount of steel in our cars! Together, the big three automakers alone spent $1.04 billion for health care benefits in 1975.

As an aside, related to the juxtaposition of automobiles and health care, we remember that it took the Arab oil boycott to demonstrate that the tragic toll in deaths and accidents on our highways could be dramatically reduced by a small reduction in the speed limit. In considering the future of health planning, the Congress was quite aware that if our interest is in improving health and in restraining the cost of medical care, we cannot concentrate all our attention on the medical care system alone.

Within this environment, the passage of Public Law 93–641 was intended to provide the structure and the support for effective health planning and a more systematic development of resources, especially new technology. A number of features were designed specifically to avert our drifting into a health care crisis of unsolvable proportions.

Public Law 93-641 added two amendments to the Public Health Service Act, Titles XV and XVI. Title XV requires the Secretary of Health, Education, and Welfare to issue guidelines, by regulation, concerning national health planning policy. The Guidelines must include:

1. Standards respecting the supply, distribution and organization of health resources.
2. And a statement of national health planning goals which must be expressed in quantitative terms, to the extent possible.

The Guidelines must be developed in consultation with a new National Council on Health Planning and Resources Development, Health Systems Agencies (HSAs), State Health Planning and Development Agencies (SHPDAs) and Statewide Health Coordinating Councils (SHCCs), which will be discussed later, as well as with organizations and associations representing the other provider and consumer groups. These guidelines will be more than national statements of values and preferences. Agencies must examine the relationship between the area's experiences and the national goals and standards and if the national priorities are not reflected in the area's goals, the agencies must explain the reasons therefor. Agencies will, of course, also deal with important local problems which are not addressed in the national guidelines.

Background work on the Guidelines has been underway for many months. In June 1975, a notice was published in the Federal Register inviting public comment and participation in the development of the guidelines, and draft materials have been circulated for public reaction. The draft guidelines include statements of general principles followed by specific goals and related sub-goals relating to health status, health promotion, health care and health financing.

There are also standards concerning the distribution and organization of health resources. For example, an upper limit on the number of beds per 1,000 persons and a minimum standard of physicians to population ratio have been suggested. A series of regional conferences on these guidelines is now being planned.

Title XV also mandated the creation of a National Council on Health Planning and Resources Development, composed of twelve public members, broadly representative of consumers, providers, health planning agencies and other qualified persons (2). The National Council is responsible for advising and making recommendations to the Secretary concerning the national guidelines, the implementation and administration of the program, and an evaluation of the implications of new medical technology for the organization, delivery and equitable distribution of health care services. To date, 5 (3) of the public members have been selected for the Council (and one preliminary meeting has been held).

To implement the law, the Congress authorized a network of areawide planning agencies, known as Health Systems Agencies (HSA's), which together will blanket the nation. Each agency is responsible for a health service area of approximately 500,000 to 3 million residents (4). The designated area is supposed to be a reasonable reflection of a health service or medical trade area with at least one center for the provision of highly specialized services. Wherever possible standard metropolitan statistical areas would fall into only one Health Service area. The provision resulted in 15 interstate HSA's.

The areas were selected by the Governors of each State under Federal guidelines (5). The designation of health service areas was completed early in 1975, though some modification of a few areas is still going on.

There are currently 212 health service areas. Of these, health service areas and State boundaries are coterminous in 10 locations. Under a special provision (section 1536) some States and territories were granted exemptions from the requirement to create a two-tiered (HSA and State) planning structure. The so-called 1536 entities include Rhode Island, the District of Columbia, Hawaii, the Trust Territories, Guam, American Samoa and the Virgin Islands.

The Health Systems Agencies may be private nonprofit corporations, a public regional planning body if it meets special requirements, or a single unit of local government. Most of the designated HSAs are private nonprofit corporations (n"174; n=18; n=4 respectively). The agencies must be governed (6) by a majority (50-60%) of consumers, with the remainder of the Board representing physicians (particularly practicing ones) dentists, nurses and other health professions, health care institutions, insurers, professional schools and the allied health professions. The statute also requires representation of public officials, residents of non-metropolitan sub-areas, and HMOs, where appropriate.

An early study of governing boards of HSAs (based on 136 HSAs) revealed that consumers accounted for 52% (n= 3,105) of the 5,940 members surveyed. Another 2,078 were classified as direct providers (physicians, nurses, health care institution administrators, dentists, health and allied health professionals).

The purposes of the planning agencies are to

• -- improve the health of residents of a health service area.
• -- increase accessibility, acceptability, continuity and quality of health services provided.
• -- restrain increases in the cost of providing health services.
• -- and prevent unnecessary duplication of health resources.

The agency's primary responsibility is the provision of effective health planning for its area and the promotion of the development (within the area) of health services, manpower, and facilities which meet identified needs, reduce documented inefficiencies and implement the health plans of the agency.

The emphasis on improving the health of the residents is especially noteworthy and troublesome in light of the growing interest and in determining more precisely the relationships between health and medical services, and health and other non-medical factors and the difficulties associated with measuring such phenomena.

To meet these responsibilities, each agency must complete a Health Systems Plan (HSP) which is a statement of long range goals for the community. Not only are the Plans themselves considered important documents for the public statement of the community's goals and objectives, but the Plan serves as the basis on which all proposals for new institutional health services and programs, and applications for Federal funds under a significant number of Federal programs will be reviewed. In addition to the long range plan, there must be an Annual Implementation Plan which has specific objectives for each year or group of years within the minimum 5 year planning horizon of the HSP.

The agencies will also make recommendations to the State concerning projects for distribution of funds for modernization, construction and conversion of medical facilities, as well as review and make recommendations on proposals for new services and capital expenditures. Agencies will be reviewing existing services in terms of their appropriateness. In conducting these activities, agencies are required to coordinate with other Federally sponsored initiatives (e.g. PSROs and the Cooperative Health Statistics System), as well as existing planning activities under State and local agencies.

The Health Systems Plans for each area in the State serve as the basis for the State Health Plan.

The State Health Planning and Development Agency

To assure coordinated State level planning, an agency of State government, chosen by the Governor, is designated to serve as the State Health Planning and Development Agency (SHPDA). The SHPDA must have an administrative program approved by HEW for carrying out its functions.

The State Health Planning and Development Agency is responsible for conducting the State's health planning activities and implementing the parts of the State Health Plan and plans of Health Systems Agencies which relate to the government of the State. The agency will prepare a preliminary State plan from the Health Systems Plans for approval or disapproval by the Statewide Health Coordinating Council. The SHPDA prepares and assists the Council in the review of the State medical facilities plan and in the performance of its functions.

It serves as the designated planning agency under Section 1122 (capital expenditures review) of the Social Security Act if the State has made an agreement and administering a State certificate of need program of comparable scope (7), reviews new institutional health services proposed and the appropriateness of existing institutional health services.

The law also mandated the creation of Statewide Health Coordinating Councils (SHCC) whe...

Table of contents

• Cover
• Half Title
• Series Page
• Title
• Copyright
• Contents
• Foreword
• About the Editors
• About the Authors
• Introduction
• 1 Health Planning in the United States: Where We Stand Today
• 2 National Health Data for Policy and Planning
• 3 Unmet Health Care Needs and Health Care Policy
• 4 Future Directions in National Health Policy
• 5 Readiness of Sociomedical Sciences to Measure Health Status
• 6 The Measurement of Psychological Well-Being
• 7 Measurement of Oral Health Status
• 8 Methodological Perspectives on Health Status Indexes
• 9 Health Status Indicators as Tools for Health Planning
• Index