11.

3.

The governor may appoint the SHCC chairperson.

4.

5.

The governor may appoint up to 50% of the SHCC from
other than HSA representatives. (No HSA should be
entitled to a majority position on the SHCC).

In

The SHCC, in consultation with the governor, may
approve a functional division of labor between the
single state HSA and the SHPDA, but only if this new
division of labor involves functions, goals, and
priorities already prescribed by P.L. 93-641.
addition, if this new division of labor involves a
change in a functional role for the SHCC (different
from that specified in P.L. 93-641), the Secretary
of HEW must review and approve any change in the
SHCC role.

This proposal is designed to avoid disruption of existing
working relationships in single HSA states (points 1 and
2); gives the governor an opportunity for input within
the present framework of the law (points 3 and 4); fosters
integrated planning between the SHPDA and HSAs, taking
into account statewide policy (point 5); and most impor-
tantly allows the HSA and SHPDA, with approval of the
SHCC, to work out procedures which best fit the needs of
each single HSA state as a function of its distribution
of services while providing for effective representation
of local and substate interests (point 5).

AHPA also submits the following amendments to Sections 1512(b)(4), 1513(a)(4), and 1513(b) (3) which provide protection against anti-trust and other damage suits for board members and employees of planning agencies as well as health care organizations and their staffs and boards, who voluntarily comply with planning agency review.

As amended, Section 1512(b)(4) should read:

"no individual who, as an employee, agent, or member
of the Board of Directors of a Health Systems Agency,
an employee or agent of a State Health Planning and
Development Agency, or a member, employee, or agent
of a Statewide Health Coordinating Committee, and the
organizations, their employees, Board members,

46-585 0 - 79 13

and agents who voluntarily follow the recommendation
of a SHPDA or HSA made in conformance with the re-
requirements of this act, shall, by reason of perfor-
mance of any duty, function, or activity required of,
or authorized to be undertaken by the agency under
this title, be liable for payment of damages under
any law of the United States or any State (or political
subdivision thereof) if he could have reasonably be-

lieved he was acting within the scope of such duty,

function, or activity."

Section 1513(a) (4) is amended by adding to the last sentence:
"....and in so doing such agency shall not be liable for
the payment of damage under any law of the United
States or any State or political subdivision thereof,
if with respect to carrying out those functions the
agency acts within the scope of such duty, function,
or activity."

Section 1513(b)(3) is amended by adding after "area":
"; such objectives may include plans and projects for
individual institutions and services."

These amendments, together with the proposed language in H. R. 3041 which require the same public process and final public ratification for the Annual Implementation Plan that is now required in P.L. 93-641 for the Health Systems Plan and State Health Plan, clarify the conditions under which planning entities and those involved in planning either as staff, board member, or provider, as well as those providers who voluntarily comply with such agencies, are in conformance with the requirements of P.L. 93-641, and therefore eligible for its protection.

Failure to provide the necessary protection would discourage the active citizen participation necessary to the success of the program. It would inhibit voluntary action by providers, acting under HSA guidance, under full public scrutiny and ultimate state or federal authority, to work toward proposed solutions to problems of facility conversion, closure, and consolidation. To provide assurance of protection, we believe federal protection should be extended to individuals who are employed by SHPDAs and SHCCs as well.

SECOND REPORT ON 1978 SURVEY

APPENDIX A

OF HEALTH PLANNING AGENCIES, FEBRUARY, 1979

EXECUTIVE SUMMARY

This report summarizes the data obtained by the AHPA survey of health planning agencies concerning their activities for the 24-month period ending August, 1978. The data focus on five areas: (1) the formal review of capital investments proposed under State Certificate of Need Programs or "1122 agreements", (2) the "unofficial" actions by HSAS/SHPDAs that discourage capital investment proposals, (3) the review of proposed uses of Federal funds (PUFF), (4) the provision of technicial assistance, and (5) major implementation problems.

The survey was conducted because some relevant major national policy issues concerning P.L. 93-641-cost containment, health promotion, etc. are being debated in the absence of any reliable data, from the nation as a whole, on the impact of the planning agencies. The Federal government has invested many millions of dollars in the development of the health planning agencies; States and localities have added more dollars to the investment; and thousands of individuals, citizen volunteers, have contributed millions of hours of effort. The two major objectives of the planning agencies are "cost containment" and "health care system improvement". The extent to which these objectives are being reached remains unknown, except on an anecdotal basis; hence, this survey.

Who responded to the survey?.....

Eighty-one percent of the HSAs (166 of 204) and fifty-three percent of the SHPDAS (27 of 51) responded, giving us usable data covering 88% of the U.S. population. The respondents were well distributed across the United States, by region and by rural/urban character.

What was the CON/1122 experience?......

Major Findings:

1. The reparting agencies reviewed $12 billion in capital investment proposals (of which $10.6 billion were in official Certificate of Need or 1122 applications). 2. $3.4 billion of the proposed investments were disapproved ($2.3 billion in official disapprovals).

3. In the hospital sector, 16,000 new beds were proposed (11,500 in official applications), of which 7900 will not be built (3700 officially disapproved).

4. For skilled nursing homes and intermediate care facilities, 114,000 new beds were proposed (85,000 officially). 49,000 did not get approved (20,000 officially denied).

5. The "operating costs" saved as a consequence of the capital investment denials are more difficult to quantify but would have to exceed $10 billion for the

decade of the 1980s.

6. For the reporting areas, the amount of proposed capital investment reviewed per capita, for those 2 years, was $78.50 ($65.15 officially); the amount denied was $26.45 ($13.97 officially).

7. The total amount invested in health planning per capita, for those two years, was $1.69; and the review of proposed capital investments constitutes less than half of the planning agencies' major activities.

By charting the responding agencies according to their size (population served) and when they began doing C/1122 reviews, we discover that our findings on official reviews relate to 75% of the U.S. population, for the two years under study. Data relating to capital investment proposals discarded through "unofficial" but documentable HSA actions pertain to about 45% of the U.S. population.

While there are always methodological problems with this kind of survey, we believe that they have been recognized in this effort, and the appropriate caveats have been made (see Sections II. F. and III. A. in the full repart). One of the most perplexing questions is, how does the planning/regulatory environment affect the performance of a planning agency. The following quote from one survey respor.se was echoed by many of the agencies, and exemplifies the problem:

As part

It should be emphasized that our HSA does much more than simply approve
or disapprove capital expenditure proposals. We first seek to help the
proponent of a project plan properly for a needed service. We help the applicant
(provider) develop a proposal that is consistent with identified community
needs. Most of the nursing home and home health care proposals developed
in this area during the past four years are a result of this effort.
of this "positive" planning process, as some like to call it, the HSA has
discouraged or redirected substantially more applications (particularly
for nursing homes, CT scanners and surgical centers) than it has disapproved.
In most cases it is not possible to demonstrate this quantitatively. I believe
it is fair to say, however, that this is where the HSA has been most
successful. I am personally aware of projects and proposals for more than a
dozen mursing homes, three CT scanners, three ESRD facilities, two proprietary
hospitals, two proprietary free-standing surgical centers, and two proprietary
"alcohol treatment centers" that have not been pursued or developed because
of HSA (and in some cases also SHPDA) policies, plans and analyses.

Puff Reviews.....

Given the stage of agency development during the last two years, and the lack of HEW regulations on the subject, most agencies had not begun to "review and approve or disapprove" proposed uses of Federal funds, the so-called PUFF reviews. However, many agencies were reviewing proposed Federal grant/contract applications, in order to comment on them to the Federal funding agency. The full report provides enough examples of such reviews to provide a flavor of this activity.

Technical Assistance.....

Technical assistance provided by the planning agencies, as a major planimplementation activity, consumes a large share of their resources. The kinds of technical assistance they provide clearly exemplify the nature of a planning agency's work. Same typical "technical assistance logs" are reproduced in the full report, from which we excerpt these examples:

In a midwest HSA.....

Provided technical assistance to municipal hospital to establish an ambulatory care center in conjunction with a health promotion program. Results to date include: 1) agreements made by two physicians to staff a primary care center which will be operated by a health service network; 2) tentative commitment from Blue Cross to provide grant support for the development of a demonstration health promotion program; and 3) commitment from Board of Trustees of hospital to reduce the facility's inpatient bed capacity. (130 Days of HSA staff effort)

Organized and conducted meetings with area radiologists to establish plan for future placement of CT scanners. (30 Days)

In a northeast HSA.....

Provided assistance in development of feasibility studies for establishment of HMOS in two Counties - one not funded, other still in planning stages. (5 days, Sr. Staff; 10 days, Jr. Staff)

Leadership, consultation and data regarding merger of two hospitals in a large city -- new corporation formed. (20 days, Sr. Staff; 10 days, Jr. Staff)

In a western HSA.....

Assisted Health Services, Inc., in submitting a designation request to DHEW to have most of the high desert portions of area designated as dental underserved area. Request granted August, 1977. (25 Days)

In a southern HSA.....

Organized community and provided technical support for Rural Health Initiative Planning Grants three funded, one pending. (22 Days)

Assisted in recruitment of physicians for two medically underserved counties two physicians now practicing.

(8 Days)

Arranged public service announcements on child immunizations played on 16 radio stations. (3 Days)

Implementation Problems.....

In addition to obtaining quantitative data on the agencies' actual performance, this survey elicited a wide range of agency comments regarding either their accomplishments or their disappointments and frustrations, mostly the latter. As much of the summary above deals with accomplishments, this segment will deal only with the reported "problems":

There were many complaints regarding HEW's performance in adminsitering the law, e.g.,

"There are a lot of deadlines imposed upon the HSAs while deadlines for federal actions are allowed to slip continuously. Agencies that develop early find themselves being used rather than helped."