I I ti A Systematic Approach SECOND EDITION Herbert Harvey Hyman, Ph.D. AN ASPEN PUBLICATION" Aspen Systems Corporation Rockville, Maryland London .4 non 8 HEALTH PLANNING History9 sanitary reform movement, which remained within the domain of local Regionalization of Health Facilities Community government, captured the consciences of the majority of the Population growth, the movement from rural to urban areas, and rising American public. Although enlightened studies in the field of health care medical costs were instrumental in the regionalization of health facilities promoted modern concepts of preventive medicine, the institution of such as 1920. Regionalization was the response to such needs as ade- as early programs met largely with opposition from the centers of power that would quate provision of health care facilities-expressed by many studies in have been able to make them realities. The most progressive changes were numbers of hospital beds per unit of population-and facility coordination to evolve in the early decades of the twentieth century. But again, these within a region.20 Prior to 1945, the private sector played the dominant remained sporadic forays into the realm of modem health care and were role in initiating efforts to study these needs. Each effort undertaken by a thwarted by a public that could not be convinced to support with taxes the voluntary group focused on a particular locality and generally remained kinds of programs that would have been required. The trend toward gov- separate from similar efforts undertaken by other voluntary groups. As a emment intervention in health matters was slowly, but definitely, emerg- result, ciiteria varied from study to study. ing. Society's inability to control its purse strings and the creation of the In 1920, the New York Academy of Medicine studied 180 private and federal income tax accelerated the inevitable formalized type of central municipal hospitals in New York City to determine if there were enough help. hospital beds to care for the sick. The standard measure of need used by the academy was the Public Health Service estimate @that, at any given time, approximately two percent of the population would be sick. Finding SIGNIFICANT HEALTH ISSUES: 1920 TO PRESENT that one hospital bed existed for every 200 people, the academy concluded that the health needs of the population were being met. This study marks Prior to World War 11, health care delivery and efforts to coordinate and the first formal recognition of the necessity to plan hospital needs in the plan health services were generally initiated by private (voluntary), non- United States and was followed by a number of local and regional studies .21 government agencies at the state or local levels. Studies and planning These studies were obviously categorical in approach; questions of geo- efforts were usually disease oriented, categorical or fragmented in graphical distribution and availability of hospital care to all facets of the approach, directed toward specific health problems. 19 Efforts were initi- population were never studied. ated by voluntary health groups such as the National Tuberculosis Asso- A more comprehensive study of hospital needs, "The Need for More ciation, the American Cancer Society, and the American Public Health Hospitals in Rurals Areas," by A. B. and P. Mills, was published in Association. in an attempt to coordinate the activities of these voluntary 1935.22 The authors studied the question of population density, the health agencies, the National Health Council was created. The experience number and training of physicians, and other factors related to determin- of the depression of the 1930s, World War 11, the profound rise in medical Ing need. This was the first study concerned with health service centers, care costs resulting from the increasing imbalance between supply and facilities of 250 or more beds designed to serve a population within a demand, and the expanding role of the federal government in providing 50-mile radius of the cities where they were located.23 Again, the empha- economic assistance conditioned a steady expansion of government par- sis was on the number of beds available to a population. The important ticipation in the planning, financing, and delivery of health care. This shift point of this study was the NElls' concern with the question of regional to increased government involvement in meeting health needs is best health services. illustrated by examining the major health issues of the pre- and post-World Also during the 1930s, a joint committee of the American Public Health War 11 peiiods and the responses of the private and public sectors to those Association and the National Health Council studied the provision of full- issues. time local health services in the United States. This study emphasized the Between 1920 and 1965 several major health issues emerged: regionali- provision of services nationwide rather than in specific localities. The zation of health facilities (provision and coordination of health facilities), Emerson Report, as it came to be called, was not released until the end of alternative methods of health care delivery, financing of health care, the World War 11.24 The recommendations in this report concerned traditional issues of public health services: sanitation, communicable disease control, impact of biomedical research, and health personnel. It would appear that the most consolidated effort was initiated by the voluntary and public maternal and child health, vital statistics, and public health laboratory sectors in response to the need of regionalization of health facilities. services. The report is connected to those nrevioii@Iv ci;rf-17c@.,A 1,@, 10 HEALTH PLANNING History 11 statement of minimal standards for local health services in terms of the ties. A most significant change wrought by the amendments was a shift in number of health personnel and number of beds per population unit, and emphasis from construction to planning of health services. Under the Hill- per capita expenditure. The study was notable for its new direction, but, Harris Amendments, state plans had to apply a new formula for assessing by the time of its publication, public health services had so expanded that bed need, incorporating utilization data, projected population, and occu- the standards recommended were inadequate." pancy factors. Several ambitious efforts were undertaken to coordinate health care The Hill-Burton Act and amendments are often criticized as focusing delivery during the 1930s. In 193 1, the Bingham Associates Fund, a private too narrowly on construction, with little stress on organization and distri- foundation, established a program based in Pratt Clinic and New England bution of health care facilities. It should be remembered, however, that Hospital in Boston to encourage coordination and integration of medical Hill-Burton not only introduced systematic statewide planning and mini- services for residents in rural areas of New England. The program was mum national standards for assessing hospital need, but also improved the conducted in conjunction with Tufts Medical School. In 1933, the Com- quality of care in rural America .27 The act and its amendments were limited mittee on the Cost of Medical Care published a report that recommended because the establishment of a formal relationship among hospitals or the coordination of local health services and personnel to provide maxi- health agencies was not made mandatory. 18 mum productivity of the scarce personnel and equipment.26 With the passage of Hill-Burton and the expenditure of vast funds for Thus, it can be seen that, prior to 1940, numerous studies of health care hospital construction, the federal government firmly and irreversibly services had been undertaken by diverse participants in the private sector. became part of the American health care system. National health planning These studies were conducted in response to a growing concern for ade- had been introduced. This fact, coupled with the great rise in medical costs quate provision of health facilities for a growing and more transient pop- despite federal assistance, led to the formation of a joint committee of the ulation and health services coordination to avoid duplication of services American Hospital Association and the Public Health Service in 1958. The and to combat rising medical costs. joint committee sponsored four regional conferences to develop guidelines Federal response to the issues in the 1920s and 1930s was limited. for planning a coordinated community health service system. Three years Traditionally, personal health care was provided by the private sector, following the conferences a report was issued. A rationale for areawide primarily in a one patient-one physician situation. Further, domestic health planning had been provided.29 unemployment and economic instability and the ensuing World War 11 The joint committee recommendations were formally recognized and absorbed federal efforts and dominated federal concerns. With the con- expanded by the public sector in 1963 when the U.S. Public Health Service clusion of the war, however, the federal government had more time and issued Proceduresfor Area)t,ide Health Facility Planning. While the joint money with which to examine those issues raised by the private sector. committee studies were being conducted, the American Public Health The passage of the Hospital Survey and Construction Act (Hill-Burton Association and the National Health Council sponsored an ambitious Act, PL 79-725) in 1946 was a major breakthrough in coordinating and project to produce a blueprint for a system of preventive and curative providing health care facilities nationwide. medical services and environmental health protection for the next ten The Hill-Burton Act provided federal aid to states for hospital facilities. years. Whereas the joint committee was a cooperative public and private To be granted funds, however, a state had to create a hospital planning sector venture, the National Commission on Community Health Services council responsible for assessing the need for new hospital construction. was largely a voluntary venture. The commission was funded by both the Because of this condition for funding, states were forced to survey existing private and public sectors through grants from private foundations, the facilities (number of beds per unit population) before they could apply for U.S. Public Health Service, and the Vocational Rehabilitation Adminis- construction grants. The intent of the act was to coordinate new construc- tration. tion with need and with existing facilities. The study was conducted in three parts and required four years. Part I, In 1954, the Hill-Harris Amendments to Hill-Burton revised and the National Task Forces projects, consisted of numerous autonomous expanded the program to include funding exclusively for modernization studies; consequently, the recommendations of each task force were dis- or replacement of public and nonprofit hospitals. As a result, the number jointed and published individually. Part 11, the Community Act Studies, of institutions applying for alterations and additions increased. Emphasis studied 21 individual communities throughout the United States. The find- shifted from providing hospital care in rural areas to altering urban facili- ings of each of these task groups provided the basis for recommendations 12 HEALTH PLANNING History 13 to be presented during the third part of the project-the Communications committee, culminated in a regional comprehensive philosophy of health project. This part of the project tested public reaction to the recommen- planning as opposed to the emphasis on facilities that had dominated dations at four different regional conferences. The commission's report, voluntary concerns during the 1920s and into the 1940s. This new philos- published in 1966, made the following major recommendations: ophy became law with the passage of the Partnership for Health Act of 1. Community health services need greater federal participation. 1966. 2. Comprehensive health planning must be undertaken on a continuing basis. Health Care Delivery and Financing of Health Care 3. Regional or areawide planning bodies must be established to corre- spond to problem health areas. The regionalization of health care is only one such issue to emerge 4. A single system must be established to provide personal health between 1920 and 1980. The rising cost of medical services resulted in a services that eventually will combine all parts of public and private health care.30 move to coordinate and regionalize facilities in order to make more effl- . nt use of the health care system and to avoid duplication of services. cie Concurrent with these efforts by the voluntary and public sectors to Rising costs also produced new trends in the delivery of health care and coordinate health services, the Commission on Heart Disease, Cancer, the financing of health services. and Stroke was formed by President Johnson in 1963 to recommend steps In 1933, after a three-year study of the existing system of personal health to reduce the incidence of these illnesses through new knowledge and services in the United States, the Committee on the Cost of Medical Care more complete utilization of existing medical knowledge. The recoi-nmen- published a report that illustrated the inability of a large portion of the dations of this commission were enacted into law as the Heart Disease, population to obtain high-quality medical care, owing to rising costs. The Cancer and Stroke Amendments of 1965 (PL 89-239). Even though the most significant recommendation from this committee was the concept of initial study was categorical in approach, the establishment of the Regional "pre-paid medical groups." The report states that: Medical Programs (RMPS) was a comprehensive response. Cooperative regional arrangements were to be organized from existing medical centers, medical service, both preventive and therapeutic, should be fur- clinical research centers, and hospitals. Fifty-six health regions were nished largely by organized groups of physicians, dentists, nurses established and charged with evaluating the overall health needs within and pharmacists and other associated personnel. Such groups each region. Initially, the act covered only heart disease, stroke, and should be organized around a hospital for rendering complete cancer, but the 1.970 amendments expanded the program. Two important home, office and hospital care. The form of organization should aspects of the act distinguished it from previous legislation and voluntary encourage the maintenance of high standards and the develop- group emphasis on the coordination and provision of health services. First meiit or preservation of a personal relation between patient and the act provided for local participation in planning. This approach de' physician .12 parted significantly from purely state and federal planning of facilities that were provided for in the Hill-Burton Act. Second, funding of projects was According to the committee, this system of health care services offered provided for both planning and operating. the community the maximum potential for productivity of scarce profes- Once regions were awarded planning grants, they became eligible to sional personnel and expensive equipment. apply for funds to cover operating expenses of all projects in their ju iis- The concept of prepayment and group practice expressed in 1933 was diction. Initially, funding was devoted to continuing education and train- rated into the pattern of health service delivery. In 1965, a survey incorpo ing, but this emphasis has shifted to organization and delivery of patient conducted by the Department of Health, Education, and Welfare (HEW) services, and improvement of personnel productivity and distributional of 582 group plans showed that the plans fell into five categories, depending Unfortunately, the RMPs were not incorporated into existing federal and on sponsoi- or consunici- ol-jel,tZ,tioll.33 The community-consumer plans state programs, causing both duplication and gaps in delivery of services, are nonprofit plans designed to serve the general community ora particular personnel training, and research. group. These plans incorporate prepaid medical services on a private The passage of the RMP legislation, together with the recommendations basis, not a group practice basis. The Health Insurance Program (HIP) of of the National Commission and the guidelines published by the joint Greater New York and the Kaiser Plan are well-known exam les of p