5
1
9780472111930
By Thomas P. Weil
All right reserved.
ISBN: 0472111930
1 - Forming Health Networks Is Simply Repackaging an Old Concept
ABSTRACT. Health planning has been an increasingly important endeavor in the United States since the early 1930s, when the Commission on the Cost of Medical Care (CCMC) recommended a three-tier regional approach to organizing health facilities and services. The CCMC proposed that healthcare be arranged with primary care centers referring more complex cases to secondary-type providers and tertiary services being offered at major medical centers with teaching and research capabilities. Over the next six and a half decades this concept was embellished with the advent of the Hill-Burton program, comprehensive health planning, health system agencies, multihospital systems, health alliances, integrated delivery systems, and health networks. This chapter's major theses are that these latter health planning approaches were modeled along the same conceptual framework suggested earlier in the CCMC's final report, and, therefore, health networks or networking could well be considered "old wine simply being rebottled or repackaged" to meet an increasingly complex and far more competitive environment.
Objectives for health planning such as enhancing access, social equity, and quality and reducing costs are easy to explain, yet for the past sixty-five years health networking has been difficult to implement because the United States has a highly politicized, pluralistic approach to delivering healthcare; self-interest among consumers and providers is pervasive; most communities are reluctant to expend significant resources for general planning purposes or for consumer-oriented studies that might determine local healthcare priorities; there is lack of agreement among professionals on what critical quantitative measures to use when evaluating healthcare needs; and among most Americans there is an intense fear that health planning can result in restricting one's ability to obtain quality healthcare as well as infringing on one's political freedom.
The Planning Process
The formation of a health network or an alliance is now a familiar and acceptable phrase, but several decades ago the mere mention of this approach conjured up visions of infringement on institutional and personal freedom and more governmental regulation. In the 1930s and 1940s health and hospital leaders such as Bachmeyer, Davis, Falk, Goldwater, MacEachern, Mountain, Ring, and Rorem, wrote frequently on the need to develop regional health systems. This concept received minimal heed among practitioners in the field until the late 1970s, when the multihospital system model became conventional wisdom. A decade later health networking gained momentum as a result of increased enrollment in managed care plans and a growing surplus of inpatient facilities, tertiary services, and physician manpower among the superspecialties. As a fallout of rightsizing or downsizing in almost every metropolitan area, there has been a mammoth surge of mergers of various types throughout the United States, creating numerous huge and powerful health networks.
Opposition to planning has faded with the course of contemporary social, economic, and political events. Although resistance to regional planning exists among those with vested interests or with strong ties to the status quo, the process is generally becoming recognized in almost all circles as a legitimate activity. Citizen and consumer groups, industrial leaders, public officials, and the media are now among its strongest advocates. Even special interest groups, who were originally most hostile to the concept, have reluctantly come to the conclusion that planning health services, often previously left to the discretion of the market or to the ingenuity of its participants, must now be subjected to more responsible scrutiny.
Planning in the United States is primarily a long-range endeavor, looking backward to be sure about historical trends, looking around at current developments, and primarily searching for options and recommendations that steer the public to the most positive outcomes in the future. Myrdal attributes America's historical resistance to its planning efforts to fears surrounding governmental intervention and "a general tendency to nearsightedness among both politicians and experts." Many have feared that broad and comprehensive planning would yield intolerable tyranny and control and would thereby become a frightful influence over one's livelihood as well as one's political freedom.
The rapid pace of industrialization and urbanization and their resultant problems have encouraged, in spite of fears about more centralized control, a more favorable attitude nationally toward planning. Local leaders and citizens alike have become increasingly aware of the foolhardiness of their regional health delivery systems making significant changes in their governance or how they deliver health services without some prior long-range strategic planning efforts.
Today the need to plan is no longer seriously debated, yet with this often arduous process a number of questions arise. What conceptual framework should be utilized in a regional planning endeavor? What specific criteria should be used? What data and other information should be collected to plan most effectively for a region's delivery of health services? Who is responsible for bringing about wise regional health planning decisions? Should major regional health policy changes undergo any external public review and, if so, by whom?
Although responding to these questions could be intellectually stimulating, the purposes of this chapter are more limited: (1) to demonstrate that health planning concepts as they are currently being pursued by America's health networks are consistent with earlier regional approaches (i.e., these new alliances should not be considered as a new or a novel approach); and (2) to propose that America's health networks face many of the same issues in achieving improved access, social equity, and quality and reducing costs as earlier attempts to regionalize health resources or to implement comprehensive health planning concepts. This chapter argues that the regionalization of health services is an old concept that has been supported by private and public sponsors for decades and that the issues and problems in currently applying this concept are the same as those experienced over the past sixty-five years.
Planning Is an Old Concept
Many cities, towns, and corporations throughout the world have produced some form of blueprint that delineates their aims, objectives, and physical development. Evidence for the design and use of such plans to build their central cities can be found in ancient Greece and Rome, in the villages of medieval Europe, and in many New England towns. Major L'Enfant's design for the physical layout and development of our nation's capital is one of the more outstanding instances of American city planning.
Social, economic, and health planning, as a distinctive organizational process, became a basic discipline of study roughly seventy years ago. The pioneering work of Stein, the New York Commission of Housing and Regional Planning, Mumford, and MacKay are examples of the concern of social scientists and others in the 1920s with city and regional planning and the development of conservation programs and recreational resources. Their major objective was to improve the ills of the cities caused by the industrial revolution. Although these early studies appear simplistic in the light of today's needs and conditions, their continued use and enhancement might have given us today cities of greater beauty and livability. The tragedy is that urban planning has been largely ignored until relatively recently because of what Woodbury refers to as the "intellectual blight of laissez faire."
Although there was some economic planning prior to World War I, it was the depression of the 1930s that first demonstrated the overriding need for attention to private and public expenditures, interest rates, and levels of employment. With the formation of such groups as the Council of Economic Advisors, the Congressional Joint Economic Committee, and the Committee for Economic Development, economic planning had become an essential and legitimate function in American society. Health-care planning as we recognize it today formally started during the same period.
Commission on the Cost of Medical Care
Regional and comprehensive healthcare planning in the United States can be traced back to the establishment in 1929 of the Committee on the Costs of Medical Care (CCMC). This committee was formed in response to the desire of leading physicians, experts in public health, and social scientists for sound studies on the economic and social aspects of delivering health services. Supported by one million dollars from six foundations, the committee and its staff studied the incidence of disease and disability in the United States, how to improve the integration of healthcare facilities and services, the relationships of family income and the receipt of health services, and the income earned by health providers.
Citing the rising costs for the diagnosis and treatment of illness and disability and the inequitable distribution of health services across the nation, the committee's final report (i.e., the majority of the committee, since there were several important dissenting opinions) recommended the regionalization of health resources by coordinating primary and specialty services within a defined geographic area, the establishment of medical group practices, and the formation of not-for-profit group prepayment plans.
In the CCMC context regionalization denoted integrated networks, with primary care being delivered through rural or outlying hospitals and ambulatory care centers; secondary (more specialized, consultant care) services located at district, or "intermediate," hospitals; and tertiary (highly specialized, technologically based care) provided at major teaching centers. In other words, a conceptual framework similar to that being proposed by most health networks today.
Following the CCMC recommendations, the Bingham Associates Fund in rural New England worked to coordinate medical services for its residents by developing linkages to the New England Medical Center and the Tufts University School of Medicine. Later, in Michigan, the Hospital Survey Commission explored the state's bed needs in the context of a carefully designed regional plan.
The most controversial CCMC recommendation called for an integration of medical group practice and group (voluntary) prepayment for the enhanced provision and financing of health services. Even though the majority report endorsed group health insurance coverage, it opposed compulsory national health insurance. A voluntary plan was considered by the majority as a desirable first step. It was argued that it would be better to develop strong group practice arrangements before insurance became compulsory, since a prepaid approach would tend to freeze individual medical practice in place.
The sharpest dissent in the CCMC report to the majority's recommendations concerned group practice and came from eight of the committee's private practitioners, who viewed the proposal as a "technique of big business . . . and that of mass production." They also opposed the majority's recommendation that these medical group practices be located in or adjacent to hospitals. The eight physicians proposed that "general practitioners should be restored to their central place in medical practice" and that prepaid health insurance should only be available when such plans "can be kept under professional control and destructive competition is eliminated."
Although there was a lack of consensus on several major recommendations, over succeeding decades the CCMC report stimulated a number of significant changes in the delivery of healthcare services (e.g., Blue Cross / Blue Shield and the early prepaid group practice plans). Also, it is rather significant that some of the arguments expressed in the CCMC report about how healthcare services should be organized and financed- and therefore affect the viability of various health planning options-for the next six and a half decades emerged from similar interest groups. Most of the CCMC proposals are still currently applicable, with a number of the recommendations being as contentious today as they were in the early 1930s.
The Hill-Burton Act
The first major attempt by the federal government to translate the CCMC planning concepts into action came in 1946 with the passage of the Hospital Survey and Construction Act, better known as the Hill-Burton program. The purposes of the act were to enhance acute care services on the basis of hospital bed-to-population ratios and to build newer facilities. Because of the Depression and later World War II, only modest hospital renovation or expansion had occurred during the prior 15 years.
The Hill-Burton program provided federal grant assistance to the states for surveying their health needs, and, based on these findings, they were able to develop priorities for hospital facility construction. With well-documented plans for expanding facilities, and with minimum standards for hospitals incorporated into state licensing laws, federal funds were made available on a priority basis, and the monies were matched up to one-third of the total project cost to construct and equip public and voluntary nonprofit general, mental, tuberculosis, and chronic disease hospitals and public health centers.
The program's mandate for issuing a state health facilities plan, and the requirement that a single state agency would assume responsibility for its development and program implementation, were significant. For the first time, a determination of need for construction and renovation was available to form the basis of priorities for action, and such rankings were to be explicitly stated. Rather than first insisting on the coordination and integration of health resources and on that basis proceeding with the construction of needed facilities and services, the law emphasized building or renovating acute care beds. The Hill-Burton program is thus typically viewed as a single state agency primarily responsible for the orderly management of federal funds and not as a means to regionalize health services. Forcing hospitals and other providers to undertake joint planning as a condition for future federal funding would simply have been politically unacceptable.
The legislation that continued the Hill-Burton program into the 1970s not only maintained the grant program but also provided both guaranteed and direct loans for construction, modernization, or replacement purposes. With regard to area-wide planning, the continuing legislation stipulated that, in order to be approved, projects must comply with plans established by state or area-wide planning agencies, this provision serving as a major foundation for the passage of the Comprehensive Health Planning (CHP) Act of 1966.
The Hill-Burton program was not an unqualified success. It focused on institutional rather than comprehensive, regional approaches to remedy health delivery system inadequacies. Its overwhelming emphasis on reducing acute care bed scarcity indicated the absence of a broader goal-setting process rooted in identified community needs. Unfortunately, the Hill-Burton planning efforts involved minimal interaction between providers and consumers and between Hill-Burton officials and other voluntary health planning agencies.
The Comprehensive Health Planning Act of 1966
During the tenure of the 89th Congress, in 1966, more health legislation affecting the organization, financing, and delivery of health services was enacted than in any prior period. Medicare; Medicaid; the heart disease, cancer, and stroke centers (i.e., the regional medical program); and the comprehensive health planning initiative, with their respective issues relating to appropriate implementation, placed on the nation's threshold a major shift in health policy. These federal provisions went a long way in affirming, conceptually and pragmatically, a number of important dimensions of the principle that all Americans are entitled to comprehensive health services of high quality, regardless of income, ability to pay, or age.
Referred to colloquially as the "partnership for health bill," the Comprehensive Health Planning and Public Health Service Amendments Act of 1966 (P.L. 89-649) was drafted by a team of representatives from the Association of State and Territorial Health Officers, the Association of State and Territorial Mental Health Officers, and the United States Public Health Service. The act, signed into law by President Lyndon Johnson, incorporated a two-pronged strategy for beefing up and expanding state influence and responsibility in health planning matters.
The law's first objective was to encourage the states to develop and carry out comprehensive health planning, both for the state as a whole and within regional and local areas. Its purpose was to promote a unification of all of the vital threads-hospitals and related facilities, manpower and population health needs-to permit more rational decision making and enable the states to provide more meaningful direction of the total health effort.
The second objective was to give state health agencies greater administrative freedom and flexibility in setting priorities. Toward this end former categorical federal grant programs were replaced by a system of non-categorical, or block, grants. This change occurred as a result of significant criticism about the inefficiencies of various categorical grants. A noncategorical approach, it was proposed, would have the effect of focusing programs on people instead of specific diseases. Depending on its population and level of financial need, each state was now given a lump-sum allotment.
The first approach, outlined in section 314a, encouraged the states to establish and maintain a comprehensive plan for tying together the total health effort and to establish priorities. To qualify for planning and non-categorical grant support, each state was required to establish or designate a single state agency-not necessarily the health department-to carry out the prescribed planning. Furthermore, for purposes of policy formulation and the establishment of general targets and goals, each state was required to establish a broadly representative planning council to advise the agency in its planning activities. A majority of the council members were required to be consumer representatives.
Continues...
Health Networks: Can They Be the Solution? available in Hardcover
Health Networks: Can They Be the Solution?
by Thomas P. Weil PhD
Thomas P. Weil PhD
- ISBN-10:
- 0472111930
- ISBN-13:
- 9780472111930
- Pub. Date:
- 05/17/2001
- Publisher:
- University of Michigan Press
- ISBN-10:
- 0472111930
- ISBN-13:
- 9780472111930
- Pub. Date:
- 05/17/2001
- Publisher:
- University of Michigan Press
Health Networks: Can They Be the Solution?
by Thomas P. Weil PhD
Thomas P. Weil PhD
Hardcover
$94.95
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Overview
Thomas P. Weil believes that the formation of health networks, or integrated delivery systems, represents a more sophisticated attempt to restructure America's health system than those previously undertaken. He argues that this is so because integrated delivery systems require the application of established business principles and well-researched clinical acumen to the delivery of medical care services. This book evaluates whether recently formed health networks can generate enough fiscal savings to provide greater access to and quality of health care despite the current trend of cutbacks in reimbursement from Medicare and managed care plans.
Unfortunately, most hospitals that have formed alliances with a previous competitor or nearby teaching facility have found that they are not yet achieving the savings originally forecast. Weil finds that these shortcomings often have been caused by the difficulties in achieving a strategic fit between two partners, in finding a middle ground when differences in culture and values surface, and in implementing operational efficiencies. The book concludes with a discussion of a number of ways in which networks might cut costs in the future.
Health Networks will be of interest to medical practitioners and administrators, as well as to students in health services management programs.
Thomas P. Weil is President, Bedford Health Associates, Inc., management consultants for health and hospital services.
Unfortunately, most hospitals that have formed alliances with a previous competitor or nearby teaching facility have found that they are not yet achieving the savings originally forecast. Weil finds that these shortcomings often have been caused by the difficulties in achieving a strategic fit between two partners, in finding a middle ground when differences in culture and values surface, and in implementing operational efficiencies. The book concludes with a discussion of a number of ways in which networks might cut costs in the future.
Health Networks will be of interest to medical practitioners and administrators, as well as to students in health services management programs.
Thomas P. Weil is President, Bedford Health Associates, Inc., management consultants for health and hospital services.
Product Details
| ISBN-13: | 9780472111930 |
|---|---|
| Publisher: | University of Michigan Press |
| Publication date: | 05/17/2001 |
| Edition description: | First Edition |
| Pages: | 392 |
| Product dimensions: | 6.00(w) x 9.00(h) x 1.20(d) |
About the Author
Thomas P. Weil is President, Bedford Health Associates, Inc., management consultants for health and hospital services.
Read an Excerpt
Health Networks: Can They Be the Solution?
By Thomas P. Weil
University of Michigan Press
Copyright © 2001 Thomas P. WeilAll right reserved.
ISBN: 0472111930
1 - Forming Health Networks Is Simply Repackaging an Old Concept
ABSTRACT. Health planning has been an increasingly important endeavor in the United States since the early 1930s, when the Commission on the Cost of Medical Care (CCMC) recommended a three-tier regional approach to organizing health facilities and services. The CCMC proposed that healthcare be arranged with primary care centers referring more complex cases to secondary-type providers and tertiary services being offered at major medical centers with teaching and research capabilities. Over the next six and a half decades this concept was embellished with the advent of the Hill-Burton program, comprehensive health planning, health system agencies, multihospital systems, health alliances, integrated delivery systems, and health networks. This chapter's major theses are that these latter health planning approaches were modeled along the same conceptual framework suggested earlier in the CCMC's final report, and, therefore, health networks or networking could well be considered "old wine simply being rebottled or repackaged" to meet an increasingly complex and far more competitive environment.
Objectives for health planning such as enhancing access, social equity, and quality and reducing costs are easy to explain, yet for the past sixty-five years health networking has been difficult to implement because the United States has a highly politicized, pluralistic approach to delivering healthcare; self-interest among consumers and providers is pervasive; most communities are reluctant to expend significant resources for general planning purposes or for consumer-oriented studies that might determine local healthcare priorities; there is lack of agreement among professionals on what critical quantitative measures to use when evaluating healthcare needs; and among most Americans there is an intense fear that health planning can result in restricting one's ability to obtain quality healthcare as well as infringing on one's political freedom.
The Planning Process
The formation of a health network or an alliance is now a familiar and acceptable phrase, but several decades ago the mere mention of this approach conjured up visions of infringement on institutional and personal freedom and more governmental regulation. In the 1930s and 1940s health and hospital leaders such as Bachmeyer, Davis, Falk, Goldwater, MacEachern, Mountain, Ring, and Rorem, wrote frequently on the need to develop regional health systems. This concept received minimal heed among practitioners in the field until the late 1970s, when the multihospital system model became conventional wisdom. A decade later health networking gained momentum as a result of increased enrollment in managed care plans and a growing surplus of inpatient facilities, tertiary services, and physician manpower among the superspecialties. As a fallout of rightsizing or downsizing in almost every metropolitan area, there has been a mammoth surge of mergers of various types throughout the United States, creating numerous huge and powerful health networks.
Opposition to planning has faded with the course of contemporary social, economic, and political events. Although resistance to regional planning exists among those with vested interests or with strong ties to the status quo, the process is generally becoming recognized in almost all circles as a legitimate activity. Citizen and consumer groups, industrial leaders, public officials, and the media are now among its strongest advocates. Even special interest groups, who were originally most hostile to the concept, have reluctantly come to the conclusion that planning health services, often previously left to the discretion of the market or to the ingenuity of its participants, must now be subjected to more responsible scrutiny.
Planning in the United States is primarily a long-range endeavor, looking backward to be sure about historical trends, looking around at current developments, and primarily searching for options and recommendations that steer the public to the most positive outcomes in the future. Myrdal attributes America's historical resistance to its planning efforts to fears surrounding governmental intervention and "a general tendency to nearsightedness among both politicians and experts." Many have feared that broad and comprehensive planning would yield intolerable tyranny and control and would thereby become a frightful influence over one's livelihood as well as one's political freedom.
The rapid pace of industrialization and urbanization and their resultant problems have encouraged, in spite of fears about more centralized control, a more favorable attitude nationally toward planning. Local leaders and citizens alike have become increasingly aware of the foolhardiness of their regional health delivery systems making significant changes in their governance or how they deliver health services without some prior long-range strategic planning efforts.
Today the need to plan is no longer seriously debated, yet with this often arduous process a number of questions arise. What conceptual framework should be utilized in a regional planning endeavor? What specific criteria should be used? What data and other information should be collected to plan most effectively for a region's delivery of health services? Who is responsible for bringing about wise regional health planning decisions? Should major regional health policy changes undergo any external public review and, if so, by whom?
Although responding to these questions could be intellectually stimulating, the purposes of this chapter are more limited: (1) to demonstrate that health planning concepts as they are currently being pursued by America's health networks are consistent with earlier regional approaches (i.e., these new alliances should not be considered as a new or a novel approach); and (2) to propose that America's health networks face many of the same issues in achieving improved access, social equity, and quality and reducing costs as earlier attempts to regionalize health resources or to implement comprehensive health planning concepts. This chapter argues that the regionalization of health services is an old concept that has been supported by private and public sponsors for decades and that the issues and problems in currently applying this concept are the same as those experienced over the past sixty-five years.
Planning Is an Old Concept
Many cities, towns, and corporations throughout the world have produced some form of blueprint that delineates their aims, objectives, and physical development. Evidence for the design and use of such plans to build their central cities can be found in ancient Greece and Rome, in the villages of medieval Europe, and in many New England towns. Major L'Enfant's design for the physical layout and development of our nation's capital is one of the more outstanding instances of American city planning.
Social, economic, and health planning, as a distinctive organizational process, became a basic discipline of study roughly seventy years ago. The pioneering work of Stein, the New York Commission of Housing and Regional Planning, Mumford, and MacKay are examples of the concern of social scientists and others in the 1920s with city and regional planning and the development of conservation programs and recreational resources. Their major objective was to improve the ills of the cities caused by the industrial revolution. Although these early studies appear simplistic in the light of today's needs and conditions, their continued use and enhancement might have given us today cities of greater beauty and livability. The tragedy is that urban planning has been largely ignored until relatively recently because of what Woodbury refers to as the "intellectual blight of laissez faire."
Although there was some economic planning prior to World War I, it was the depression of the 1930s that first demonstrated the overriding need for attention to private and public expenditures, interest rates, and levels of employment. With the formation of such groups as the Council of Economic Advisors, the Congressional Joint Economic Committee, and the Committee for Economic Development, economic planning had become an essential and legitimate function in American society. Health-care planning as we recognize it today formally started during the same period.
Commission on the Cost of Medical Care
Regional and comprehensive healthcare planning in the United States can be traced back to the establishment in 1929 of the Committee on the Costs of Medical Care (CCMC). This committee was formed in response to the desire of leading physicians, experts in public health, and social scientists for sound studies on the economic and social aspects of delivering health services. Supported by one million dollars from six foundations, the committee and its staff studied the incidence of disease and disability in the United States, how to improve the integration of healthcare facilities and services, the relationships of family income and the receipt of health services, and the income earned by health providers.
Citing the rising costs for the diagnosis and treatment of illness and disability and the inequitable distribution of health services across the nation, the committee's final report (i.e., the majority of the committee, since there were several important dissenting opinions) recommended the regionalization of health resources by coordinating primary and specialty services within a defined geographic area, the establishment of medical group practices, and the formation of not-for-profit group prepayment plans.
In the CCMC context regionalization denoted integrated networks, with primary care being delivered through rural or outlying hospitals and ambulatory care centers; secondary (more specialized, consultant care) services located at district, or "intermediate," hospitals; and tertiary (highly specialized, technologically based care) provided at major teaching centers. In other words, a conceptual framework similar to that being proposed by most health networks today.
Following the CCMC recommendations, the Bingham Associates Fund in rural New England worked to coordinate medical services for its residents by developing linkages to the New England Medical Center and the Tufts University School of Medicine. Later, in Michigan, the Hospital Survey Commission explored the state's bed needs in the context of a carefully designed regional plan.
The most controversial CCMC recommendation called for an integration of medical group practice and group (voluntary) prepayment for the enhanced provision and financing of health services. Even though the majority report endorsed group health insurance coverage, it opposed compulsory national health insurance. A voluntary plan was considered by the majority as a desirable first step. It was argued that it would be better to develop strong group practice arrangements before insurance became compulsory, since a prepaid approach would tend to freeze individual medical practice in place.
The sharpest dissent in the CCMC report to the majority's recommendations concerned group practice and came from eight of the committee's private practitioners, who viewed the proposal as a "technique of big business . . . and that of mass production." They also opposed the majority's recommendation that these medical group practices be located in or adjacent to hospitals. The eight physicians proposed that "general practitioners should be restored to their central place in medical practice" and that prepaid health insurance should only be available when such plans "can be kept under professional control and destructive competition is eliminated."
Although there was a lack of consensus on several major recommendations, over succeeding decades the CCMC report stimulated a number of significant changes in the delivery of healthcare services (e.g., Blue Cross / Blue Shield and the early prepaid group practice plans). Also, it is rather significant that some of the arguments expressed in the CCMC report about how healthcare services should be organized and financed- and therefore affect the viability of various health planning options-for the next six and a half decades emerged from similar interest groups. Most of the CCMC proposals are still currently applicable, with a number of the recommendations being as contentious today as they were in the early 1930s.
The Hill-Burton Act
The first major attempt by the federal government to translate the CCMC planning concepts into action came in 1946 with the passage of the Hospital Survey and Construction Act, better known as the Hill-Burton program. The purposes of the act were to enhance acute care services on the basis of hospital bed-to-population ratios and to build newer facilities. Because of the Depression and later World War II, only modest hospital renovation or expansion had occurred during the prior 15 years.
The Hill-Burton program provided federal grant assistance to the states for surveying their health needs, and, based on these findings, they were able to develop priorities for hospital facility construction. With well-documented plans for expanding facilities, and with minimum standards for hospitals incorporated into state licensing laws, federal funds were made available on a priority basis, and the monies were matched up to one-third of the total project cost to construct and equip public and voluntary nonprofit general, mental, tuberculosis, and chronic disease hospitals and public health centers.
The program's mandate for issuing a state health facilities plan, and the requirement that a single state agency would assume responsibility for its development and program implementation, were significant. For the first time, a determination of need for construction and renovation was available to form the basis of priorities for action, and such rankings were to be explicitly stated. Rather than first insisting on the coordination and integration of health resources and on that basis proceeding with the construction of needed facilities and services, the law emphasized building or renovating acute care beds. The Hill-Burton program is thus typically viewed as a single state agency primarily responsible for the orderly management of federal funds and not as a means to regionalize health services. Forcing hospitals and other providers to undertake joint planning as a condition for future federal funding would simply have been politically unacceptable.
The legislation that continued the Hill-Burton program into the 1970s not only maintained the grant program but also provided both guaranteed and direct loans for construction, modernization, or replacement purposes. With regard to area-wide planning, the continuing legislation stipulated that, in order to be approved, projects must comply with plans established by state or area-wide planning agencies, this provision serving as a major foundation for the passage of the Comprehensive Health Planning (CHP) Act of 1966.
The Hill-Burton program was not an unqualified success. It focused on institutional rather than comprehensive, regional approaches to remedy health delivery system inadequacies. Its overwhelming emphasis on reducing acute care bed scarcity indicated the absence of a broader goal-setting process rooted in identified community needs. Unfortunately, the Hill-Burton planning efforts involved minimal interaction between providers and consumers and between Hill-Burton officials and other voluntary health planning agencies.
The Comprehensive Health Planning Act of 1966
During the tenure of the 89th Congress, in 1966, more health legislation affecting the organization, financing, and delivery of health services was enacted than in any prior period. Medicare; Medicaid; the heart disease, cancer, and stroke centers (i.e., the regional medical program); and the comprehensive health planning initiative, with their respective issues relating to appropriate implementation, placed on the nation's threshold a major shift in health policy. These federal provisions went a long way in affirming, conceptually and pragmatically, a number of important dimensions of the principle that all Americans are entitled to comprehensive health services of high quality, regardless of income, ability to pay, or age.
Referred to colloquially as the "partnership for health bill," the Comprehensive Health Planning and Public Health Service Amendments Act of 1966 (P.L. 89-649) was drafted by a team of representatives from the Association of State and Territorial Health Officers, the Association of State and Territorial Mental Health Officers, and the United States Public Health Service. The act, signed into law by President Lyndon Johnson, incorporated a two-pronged strategy for beefing up and expanding state influence and responsibility in health planning matters.
The law's first objective was to encourage the states to develop and carry out comprehensive health planning, both for the state as a whole and within regional and local areas. Its purpose was to promote a unification of all of the vital threads-hospitals and related facilities, manpower and population health needs-to permit more rational decision making and enable the states to provide more meaningful direction of the total health effort.
The second objective was to give state health agencies greater administrative freedom and flexibility in setting priorities. Toward this end former categorical federal grant programs were replaced by a system of non-categorical, or block, grants. This change occurred as a result of significant criticism about the inefficiencies of various categorical grants. A noncategorical approach, it was proposed, would have the effect of focusing programs on people instead of specific diseases. Depending on its population and level of financial need, each state was now given a lump-sum allotment.
The first approach, outlined in section 314a, encouraged the states to establish and maintain a comprehensive plan for tying together the total health effort and to establish priorities. To qualify for planning and non-categorical grant support, each state was required to establish or designate a single state agency-not necessarily the health department-to carry out the prescribed planning. Furthermore, for purposes of policy formulation and the establishment of general targets and goals, each state was required to establish a broadly representative planning council to advise the agency in its planning activities. A majority of the council members were required to be consumer representatives.
Continues...
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