I *1 ISSUE PApr.'T REGIONAL MEDICZ-.L PROG@l,!S October 19, 1972 OFFI('.F-01:' 'I') F, r!l UA RY 0 c er 19, 1972 TO : The Secretary Through OSIES : Assistant Secretary for Health and Scientific Affairs SUBJECT: Decisions on Regional Medical Programs ACTION k!E@!OPA@@@DUM This Action '.Icr,,orandum develops alternatives for the future of P,-',IPs and related @ll!) issues. It is supported' by a Summary memorandum (Tab i@), and by considerable back round material under Tab B. 9 ISSUES AND OPTIONS A. MISSION ISSUE I. WHAT SHOULD BE THE PRIORITY FUTURE MISSION (ROLE) OF R-14P? OPTION 14 IUIAP should become a pri-ncinal agency res ponsible for i.,nnle:-,cnting change in local deliverv system (ir,.olemenL--ing aaencies for CHP and other components, '.\,IH, etc.) . DISCUSSION E 1- --4-on o@-- restr4-ct@-r--@-;s on interference wi-t--h prac- anci 0- cat.c.,7orical e,-n-phaFis are ncces- r 0 Page 2 The Secretary PRO: 1. Clearly separates planning from imple- mentation. 2. Consistent with TIS.MHA's mission in delivery reform. 3. Gives' it specificity without unnecessary restriction. 4. Has been successfu 1 in the past in impl6- menting role. CON: 1. Makes it hard to evaluate. 2. Difficult to provide Fedbral direction. 3. Proposal to'eliminate categorical emphasis and restriction against "interference" with medical practice would be unpopular with ANIA and other lobbying grou@s. 4. Dependent upon emergence of an effective local planning process. 5. Would impose an untested responsibility on RMPs in terms of relationship to CHP agencies. .6.. Lack of broad representation on Board. ,,7. @IP has shown little interest in preventive health issues. 8. P14P has shown little interest in maternal and child health issues. OPTIO@L 2. R:.IP shoul.(2,-contin-ue as is -- flexible, variable, broad-authoritv which encourages providers to . 4 use ---hei--r c,,.-"n in.,t4-ati-ve to @ri-nc about chancre thev suD- port. Page 3 The Secretary PRO: 1. consistent with Departi,-en,--al and HEW/HSMHA philosophy of decentralization and local initiative. 2. Allo,,e7s flexibilities so -Ehat-the program'. s able to meet local needs in a local manner. 3. Maintains flexibility for responding to changing national priorities. 4. Consistent with past nractice which has achieved considerable professional and Congressional support.: CON: 1. May not be highly responsive to HEW priorities. 2. Evaluation is more cornlex when the program is investing in a variety of ac-Liviries. 3. Provides Federal support -for some projects WI, 4 and reforms for -Lch providers should bear the cost (e.g.i continuing education of Physicians. 4. No measurable natior.,.,7ide effect. OPTION 3. RMP should,rest@;ct its activities to "cate- gorical are,-ts"-(heart, cancer, stroke, idney). PRO-. 1. Political and Drofessional constituency easy to identify and highly supportive. 2. tasier to account for expenditures. 3. ProvidE?s ocoorL--unitv for @,:orkirg relationship .---earch and control p-carams, and the liS.,'@!iA focus on delivery activities. CO',@: 1. Tends to @L@-ag,-).cnt delivery s@rstem - obstruct c -A@ L'orts @o ii-.orove access. -ing T-@ i 2. it4o- 0- ji OPTIO!I 4. P-P-IP should emr@hasi-ze improving the uti li- zation and productivity of manpower. P'RO: 1. Consistent with HEW philosophy-of cost con- tainment and delivery reform. 2. Progress in this area cannot be achieved without the input and. involvement of pro- viders. 3. Encourages a closer relationship between the production of health manpower and their actual performance or utilization, i.e., relationship between education and health services delivery. CON: 1. Could be done well only with a consistent Federal health :,-anpo-@,7er 'strategy. Otherwise might produce scattered, inconsistent activities. 2. Creates resistance from educational insti- tutioiis which regard this as their area of responsibility. 3. Creates bureaucratic turf problems a la AHEC'S. 4. Proposed emphasis on "produc @iV4 ty" raises L. the question of whether we really know enough to accomplish this, and if we do, can we really capi- . t talize on it manipulate the system enough to use it. OPTION 5. '-UAP should.beco7pe the agency responsible for. aidina local arouses to oraanize and audit review a4-red at assessiii,,r and assuring quality of care throughout the countrv. a.,,,--' L' @,,D i-@1L-,cnc--d bv Page 5 The Secretary PRO: 1. Necessary to develop mechanisms for mea- suring quality that are workable and acceptable to providers and the community. 9. ?Iizo.-qqArv tn nroviae corrective action in response to deficiencies identified by quality monitoring. 3. only provider influenced groups will be ef- fective in this area. 4. Efforts to develop peer review mechanisms require extensive resources and technical assistance to raise the level of understanding of quality monitoring, and start initial development at the State or community level. 5. National interest in developing quality as- surande activities. 6.' National need for technical assistance in quality assurance.. 7. Consistent with professional interest in many IUIP groups and staff. CON: 1. Difficult to measure results. 2. The costs of this effort might better be borne by provider groups than HEII. 3. Local PSRO groups may not accept RMP in- Volvement. 4. Many P-,NIP'smay resist-- assignment. OPTIO-,-4 6. i@,,!P should became a@c;nc@7 responsible for monitor--ng qualit,.! of care. Page 6 - The Secretary PRO: 1. Federal need to take more positive leader- ship to provide an alternative to or im- lenent PSROs and quality assurance mechanisms which p completes the cycle of: (a) development of monitoring systems; (b) actual monitoring itself;, and (c) correc- iAnn+-i-F-ic3tl rlpfir:i.p-ncv. 2. All pro-arguments in o@tion 5. 3. The most appropriate existing institution which relates to a greater range@of provider groups than just medical societies, as in PSROS. CON: 1. Not all -@lPs are equipped to handle this responsibility. 2. Raises the Question of whether providers should dominate regulation of their own activities. 3. Monitoring or regulatory power would jeop- ardize relationship that MiPs have developed with providers. Would probably limit P-NIP to that activity because PL@IP would occupy an antagonist role with provider colleagues. 5.' Most R.NlPs would probably resist assignment. OPTION 7. PDLD should be eliminated comnietely-. PRO: 1. In times of budget stringency substantial money could be saved. 2. Provider urinated @rrour)s fill not bri,na about major ciange in delivery s,,,s"--e.,i. 3. See criticisms of Program in Section of T r_-ilb B. Page 7 The Secretary CON: 1. Has taken 5 years to develop a workable link between Federal Government and pro- viders of care; this would be lost. 2. Provides a flexible implementing mechanism at the community level to worK on proDiem areas. 3. May not be politically viable. 4. See Program Strengths in Sectibn'I of narrative. OPTION 8. @TIP should be eliminated as a Federal ldro- gram; corresoondinq funds should be applied to health revenue sharing. PRO: 1. The Secretary has made a preliminary deci- sion to this effect. 2. In addition to the PSROs under Olo-uion 7, the revenue sharing approach is probably more acceptable, olitically, than outright elimination of p the program. CON: 1. Has taken 5 years to develop a workable link between Federal Government and providers of care; this would be lost. 2. Provides a flexible implementing mechanism at the community level to work on problem areas. 3. May not be-politicallv viable. 4. See Proqram Strengths in Section I of'narra- tive. Page 8 The Secretary RECOY@@@ENDATION Primary t@lission Secondary @Lllission Not Reco,-j-.ended RATIONALE CONCUR NONCONCUR CODLMENTS AliD SUGGESTIONS Page 9 The Secretary B. DECENTPALIZAmfION AND FLPI4DING ISSUE II. G!Vr_Tq H's RECO,@P4EI\IDA'I'IUNS AS I10 Rmv M.Ltiti-Lui@, WIIAT SHOULD BE THE EXTENT OF DECENT.RALIZA- TION OF AUTHORITY TO THE LOCAL R-MPS? DISCUSSION This issue is closely related to ISSUE I MISSION. OPTION 1. CoTn.Dlete local autl-ioritv. PRO: 1. Most nearly consistent with Administration philosophy of decentralization., State res- ponsibility, and local initiative. 2. Most acceptable to the'@iPs and provides. 3. Most compatible with relating to local-ne@eds, . objectives, and resources, and resultant local.variations in approach and priorities as deter" mined'by CYIP. CON: 1. May not address priorities set by identified RYIP mission. 2. In face of funding.constrain@us and nossible cutbacks, i@ is unreasonable to expdcl-- rapid reorientation in line with new mission in absence of Federal direction'. 3. have little imnact on na+--ional objectives. Page 10 The Secretary OPTION 2. Partial, with local P-NiPs having latitude e specific nronosais within the broad priority areas as established by their redefined mission and local CHP plans. PRO: 1. Still reasonably consistent with Adininis- tration philosophy of decentralization. 2. Compatible with relating to local needs, variations, and CIIP planning. 3. Helps assure that @vP activities will address broad national priorities. CON: 1. V7ould not be as acceptable to RMPs and providers as oation 1. 2. V7ould not necessarily, insure that all local .Z PIlPs would adequately address each of the several- broad priority areas, e.g.,, monitoring of quality of care. OPTION 3. Minimum decentralization -- discretion re best methods of carrvinq out a strong Federal directive. PRO: 1. i-loul-d most nearlv insure that local iulPs address broad priorities. 2. Important in achieving missions which warrant continuing support of !U-'AP. Page 11 The Secretary CON: 1. Totally inconsistent with HEI@ deitentraliza- tion philosophy of local initiative to meet local problems. 2. unlikely that providers would willingly ac- z 3. Runs counter to actual long-term trend of increasing decentralization to local MLPS. OPTION 4. Determine national objectives at the Federal level; assign to CHP responsibility for deter- mining the degree to which national objectives are being met in the various States, and assign k@-6 @%IP a major im- ple,-.ehtina resDonsibilltv for realizing national ob@ec- tives in accordance with CHP determination of relative needs. PRO: 1. To make a decentralized system accomplish na- tional objectives. There must be a clear arti- culation of these objectives; the CHP agency is the appro- priate mechanism for evaluating State and local circum- stances and problems in the light of national objectives. 2. The capabilities of @IP will be most effectively used through supporting the achievement of such objectives, and catalXzi-ng the provider sector in that direction. C O'.%, 1. The conccr)L-. c .4 health revenue sharinct-and de- centralization is to recognize State and local objectives %NThich may be di-'-4erent from national objectives. Page 12 - The Secretary 2. A stru@ture such as that proposed in this option would so limit R-TVIP that provider interest and support would be lost. RECOI,Lll@lEli'DATION RATIONALE CONCUR ... ......... NONCONCUR. ...... COI,IMENTS Al'iD SUGGESTIONS ISSUTI III. Hol,.' SI-'OUTD FU@@DS BE APPORTION-rD/DISTRIBUTED TO THE LOCAL @,4Ps? PRO: 1. Improves review of individual proposals against priorities. 2. Alloiqs better coordination of related activi- ties; helps minimize unnecessary duplication of effort. 3. Minimize local patronage and bias. CON: 1. Administratively cumbersome and costly HEW role. 2., Unlikely to correlate funding with local. needs and pro"-.1-c-'s as there would he a ten- dency for those P@,.'--Os and s@.o.-isorina institutions (e.a. medical schools) 7.ost pro@@icienk-- in grantsr,,ansh--'L-o and with the greater resources to obtain a larger share of the funds. 3.. Would not utilize the considerable local tech- nical review and decision-makihg capacity and structure that has been created by the -@',IPs over the past six years. OPTION 2. Comoetitiv6 nrocram basis. PRO: 1. I-,7ould provide better incentives for @,..'L.Ps to address Priorities. 2. Would encourage a hiah level of competition and, ti'ius, better activities. 3. Would help overcome the criticisms (CONS) OIL Page 14 - The Secretary CON: 1. Would reduce 'Llexibility once programs approved; @IlPs would tend not to be as fully and rapidly responsive to.possible changes in priorities. 2. Would tend to reward stronger Pl@lPs and not weaker ones. OPTION 3. Competitive basis with sel'ected-earmarks. PRO: 1. Earmarks would provide incentives needed to spur local R,:.IPs to engage in activi- ties addressing high but less popular priorities (e.g., quality of care monitoring) that many of them ,otherwise might be reluctant to undertake. 2. Closely coincides with present mode. 3. Offers advantages similar to Option 2. CON: 1. Earmarkina, once resorted to, sets a prece- dent for further earmarl,-ings; at the same time it is difficult to get rid of previous earmarks even though they have outlined their usefulness. 2. Disadvantages similar to Option 2. OPTION 4. Use a formula-basi-s. PRO: 1. Consistent with HElq position on local initiative. 2. Provides 'Local P-@-@.Ps with significant 4Llexibility, 3. --Store nearlv results in an equitable Q'is-"ribu@- 01-1 0-@ -@u.,,c3s to all @7'-Os. Page i5 Tne becreLary CON: 1. Lill--tle or no incentive to use funds to address national priorities. 2. Diflicult to develop a formula adequately takina into account potential resources and needs in various specifl;.c'priority areas that would be equitable to all States., OPTION 5. On a formula basis'with selected earmarks. PRO: 1. liould allocate specified sums for special priorities. 2. Provides fiscal equity to all areas. 3. Would recruire P@lPs to develop proposals within each earrar,'-,ed area, even if that resulted in funding sc-.ne i,7ea'@er pro3ects in one given prioritv area at the e>:pense of additional stronger projects in another. CON: 1. Earmarking, once resorted to, sets a nrece- dent for fur4@-her-earmarks; at the same time 4 it is difficult to get r."d of earlier ear.-.arks that have outlined their usefulness. OPTION 6. Use a combination for,-iula-comnetitive basis. PRO: 1. Provides a financial base for long-term commitment to professional staff. 2. Provides for comt)ctiti-on. CON: 1. @lav have programs :-,ending stronger projects.. i.-4on and weaker nontrior'l@@v .Lor co@cet pro4ect--s o---@- ol-: Page 16 The Secretary RATIONALE CONCUR NONCONCUR CO,7,4,MENTS @ND SUGGESTIONS -retary' Page 17 The Se- C. ORGANIZATION OF LOCAL @!P @,-TIT ISSUF, IV. FRO,",l @@l;@-T CAT--(-70PIES OF PEOPLE SITOULD -m.Y.E LAI-,7 REQUIRE REPRESE@-4T2\-TIO!@ ON THE BO-A-RD? OPTION 1. Providers, consu,-,,ers, elected' officials, low income consumers, third narties, and CHP. PRO: 1. Encourages well rounded board composition. CON: 1. May be too restrictive to be practical in all the areas. I 2. Providers may feel under-represented. OPTIOL@L 2. Providers, consumers, elected officials, low income consumers. (Eliminates from Option 1 third party and CIIP representation.) PRO: 1. Third party and consumer representation are redundant. 2. CHP representation on board is not neccssarv i--- the-/ rovic,.,., and on, or .-ev-Lc-w and approve R2.1p projects. CO@": 1. T'-.i-.-d @,-@r'L--ic3 an-!. C 1: po,., '-d@ @4--4 --nt ners- -hat pectives on p.-c@;-Dic-.n areas and ,Driorities 4%- !--o be a--'d--cssed bl,: Page 18 - The cc-cre,'-ary OPTIO@'@ 3. Provi--Ie--s, c-.nstz7,crs, elected officials, and C,,'-D. (.@,his Option eliminates desig- nation of low inco,-e consumers from Option 2.) PRO: 1. Provides more flexibility for organizing boards. CON: 1. Low income consumers often experience dif- ,-%Toes o@ oroble-,rs than do other con- ferent 4 -z L SU-T.ers and therefore might provide a good balance to the board. OPTION 4. Provi--Iers, consumers, and low income con- sumers. (This Option deletes specific men- tion of elected officials from option 2.) PRO: 1. More flex4-blc 2, an@. allo,.is for elected tion, without specifically them. CO"L%I: 1. Elected officials often are an important source of support for the program as well as sensitive to local issues and pressures. OPTION 5. Providers and nubli-c renresenl-atives. PRO: 1. 'i'llost flexible. 2. Permits (-,,ach-State to put together most effective groti,3 1-@or tl--eir o@-:n particular arca. CO,@: 1. !@v not a@@urc broa@, representation or r z, 1 eT,-= -r s Page 19 The Secretary RECO@',@!E@@"DATIO'i RATIO.@I.ALE CONCUR NONCONCUR- COZ*IENTS A@ID SUGGESTIONS Page 20 The Secretary ISSUE V. SIIOULD- POLTCY BOARD ITAVE A MI.I !U.-,I -T CO"cU-!@-!:-]R P7@RTICIPATIO@N? P,EQUIPIE@--@i OPTION 1. Yes (20 -oercenL@-) PRO: 1. Shows a clear commitment by the Department to consumer representation. CON: 1. Reduces flexibilit,,,; may not be necessary. 2. May be useless tokenism. OPTION 2. Yes (33 1/3 percen4,-) PRO: 1. Shows a stronaer co.@-nitinent to meaning- ful consumer participation and involvement in decision making. CON: 1. Same as CON 1, Option 1. OPTION 3.- Yes (51 percent PRO: 1. Sho@-is strong commitment to consumer repre- sentation. CON: 1. Same as CON 1, Option 1. 2. llav relall--ionsh-'@:-,,s with providers and has develop I" over, the past five years. Page 21 - The Secreta.--v OPTIO,@', 4. Nlo reauirc-ei,,t. PRO: 1. Most 'Lle;('@b4Llitl, T)ri i-)nf- hAA7P i-n at this time. CON: 1. Discredits HE@7 commitment to consumer participation. RECOI..r.!-vYDATTC)N RATIO-',i;,.LE C O'i%C U R ......... o@@COI.ICUR C 0 Page 22 The Secretary ISSUE VI. SIIOULD TPE LA,q TZEQUIRE rj@ll" TO HOLD P'UBL'IC HEARIi,'@,C,S ON PPOPOSED @,.IP ACTIVITIES? OPTION 1. Require RMP to hold T)ubl.ic hear3-nqs' in ad- vance 0.4 aoT)rovinc,, projects. PRO: 1. This would provide an opportunity for effoc- tive public involvement. CON: 1. This would unnecessarily duplicate existing reviews. 2. CHP should provide the primary form for public corjrent on proposed governmentally financed.actiVitic--s in the health care field. 3. Public hearings directed to the review of individual projects would,be unduly cumbersome. OPTION 2. Require RI-,IP to hold public hearings on a general outline of proposed programs but not with resnect to awards for individual -projects. PRO: 1. Provides appropriate opportunity for public input in a,sir@.pler and more expeditious manner. CON: 1 . Ilearin,,js of this sort would be too abstract .@o be effective. 2. See CO@'is under option 1. Page 23 The Secretary OPTION 3. Authorize but do not require public hear- ings. PRO: 1. This would permit RIlPs to tailor the use of the pui.)lic hearing pro'Gess appropriately to the nature of the issues that are under consideration. CON: 1. If left optional, the public hearing process would probably rarely be utilized. '&IENDATION RECON', R7iTIONALE . .......... CONCUR NONCONCUR ..... . CO@LLIENTS AND SUGGESTIONS Page 24 The Secretary. ISSUE VII. SHOULD R'-.@ll LEGISL.ATIO-,,l @r(--.UIRE CHP APPROVAL AS A PRECONDITIO'RT FOR F@I"DING RMP PROPOSALS? OLITA"@l%l 1-. l@,cqu4-r-- CIIP --pproval. PRO: 1. Strengthen CIIP. 2. Establishes planning as a precondition for, and controller of implementation. 3. Reasonably assures that Federal money will not he used in a manner inco.-apat ible with other relevant.programs. CON: 1. Heavily restricts the provider.role; may be unacceptable to providers. 2. CliPs are not qualified, technically, to con- trol provider-spor-,E:orc-d @ro-ects not to res- pond in a timely fashion; therel@ore,"this would not be a realistic requirement. OPTION 2. Provide for revic@@7 and cop.,@.ent, but not for an approval (i.e., veto) authority. PRO: 1. Less restrictive and, hence, more acceptable. 2. CHP should, at a minimum, have a review and comment role. CON: -1. CIIP should have a strongc-r..role.t-han mere reviews., a.-id cor-Tr@c- n t. r 2. c @-'L I i n greasons t C, 6 at 'a RE, Co,.',-,-IENDATION RATIONALE . . . . . . . . . . . . . . . . . . . . CONCUR NONCO14CUR . ......... ... COI,R.IENTS AND SUGGESTIONS ..........