APPENDIXES Appendix 1 SENATE REPORT NO. 93-131, SUBMITTED BY SENATOR J. GLENN BEALL, JR. NATIONAL INSTITUTE OF HEALTH CARE DELIVERY ACT OF 1973 APRIL 27, 1973.-Ordered to be printed Filed under authority of the order of the Senate of April 18, 1973 Mr. KENNEDY, from the Committee on Labor and Public Welfare, submitted the following REPORT [To accompany S. 723] The Committee on Labor and Public Welfare, to which was referred the bill (S. 723) to establish a National Institute of Health Care Delivery, and for other purposes having considered the same, reports favorably thereon with amendments and recommends that the bill as amended do pass. SUMMARY S. 723 amends the Public Health Service Act to establish a National Institute of Health Care Delivery as a separate agency within the the Department of Health, Education, and Welfare. The Institute's mission will be to carry out an accelerated multidisciplinary research and development effort to improve the organization and delivery of health care in the nation. The bill also authorizes up to eight regional centers and two National Special Emphasis Centers, a Health Care Technology Center, and a Health Care Management Center. The total authorized funding level for both the Institute and the Centers will be $100 million for the initial year, $150 million for the second year, and $180 million for the third year, for a total authorization over the three year period of $430 million. A twenty-one member National Advisory Council on Health Care Delivery will advise the Institute on the development, priorities, and execution of its program. BACKGROUND AND NEED S. 723 was introduced on February 1, 1973 by Senator J. Glenn Beall, Jr., and was cosponsored by Senators Peter Dominick, William Hathaway, Ernest Hollings, Jacob Javits, John Pastore, Ted Stevens and Milton Young. The proposal was initially introduced as S. 3329 in the 92nd Congress and was considered by the Labor and Public Welfare Committee in connection with the Health Maintenance Organization and Development Act of 1972, S. 3327. The Committee incorporated the Institute as Title V of S. 3327, which was subsequently considered and passed by the Senate on September 20, 1972, by a vote of 60-14. No opposition was voiced during Senate consideration of the HMO legislation to the Institute though the Committee made a number of modifications to the bill as introduced in order to conform it to other related provisions of S. 3327, particlarly with respect to the Commission on Quality Health Care Assurance as authorized by S. 3327. Senator Kennedy reintroduced the HMO legislation, S. 14, in this Congress in the identical form, including the National Institute of Health Care Delivery, as passed by the Senate last year. The Committee, in order to give this proposal the visibility and national attention it deserves and merits, decided to report this measure as separate legislation. The Committee was unanimous in recommending favorable action by the Senate on S. 723 but the version reported by the Committee does not contain the conforming amendments to the HMO bill referred to above, since the Committee decided to report it as a separate bill. Since World War II, the United States has invested approximately $20 billion in biomedical research. This investment has produced many dividends in terms of major medical breakthroughs and has made the nation preeminent in the world in medical research. On the other hand, comparatively small investments have been made in research and developments to improve the organization and delivery of health care. Appropriations for fiscal year 1973 contrast our investment in medical research as compared to health care delivery research. The total outlays for fiscal 1973 for the National Institutes of Health, the Federal Government's chief biomedical research organization, is estimated to be $2.009 billion, while the estimated budget for the National Center for Health Services Research and Development for the same year is $64.4 million. By citing this contrast, the Committee is not suggesting or implying that spending on medical research is out of line. To the contrary, the Committee and the Congress have supported an acceleration of the nation's research effort. The Committee does suggest that this disparity in spending between biomedical research and health care delivery research may help account for the nation's preeminence in biomedical research, the deficiencies in our present delivery system, and the growing gap between what medical science knows and what is delivered to our citizens.. The American people are aware of and grateful for the achievements of medical science, but they are also aware of this "gap" which is a source of public dissatisfaction. Our citizens marvel at the miraclelike heart transplants that are taking place, but their plea to the health care community is to make available, accessible, and affordable the achievements, methods, and procedures developed by medical science over the last quarter to one-half century. To develop the means and methods to deliver the results of medical research and know-how to our citizens, wherever they live and at a price they can afford, is the principal task facing our nation and the health community. This is the challenge that will be the work of the National Institute of Health Care Delivery. COMMITTEE CONCERNS The Committee wishes to emphasize in very strong terms that the mandate given to the National Institute of Health Care Delivery will be very difficult to carry out and that it is, therefore, essential that the activities of the Institute be undertaken in a prudent and orderly manner. The dual goals of the Institute are to enhance the breadth and effectiveness of health services research and development in the nation through an expansion of available funds and through the transfer of the National Center for Health Services Research and Development to the Institute and to create a capability to carry out health policy research, development, and training through the staff of the Institute, and the Regional and Special Emphasis Centers. While this innovative approach to policy research and formulation is, in the Committee's view, urgently needed and deserving of support, there are serious constraints which will plague this effort. These constraints are: (1) there is in the nation essentially no tradition of health policy research and development and no suitable models on which to base the establishment of a complex, large, and multi-faceted R&D effort. (2) there is in the nation essentially no body of experienced managers to initially head up an effort of the magnitude the Committee's bill ultimately envisions. (3) there is in the nation a critical shortage of qualified professional personnel in respect to the broadbased function of the Institute and, therefore, the recruitment of adequate numbers of such persons will be arduous. Given these formidable constraints, it is clear that it is not possible to draw a complete analogy between this proposed Institute and the ongoing National Institutes of Health. When the NIH was established (in 1937), there was a large pool of well-trained biomedical researchers who were then constrained principally by the lack of money and resources with which to carry out high-level biomedical research. At that time, there was also a large body of potential investigators eager for training if resources could be made available. Such is not the case in health policy research today, in which there is only a small body of practitioners from economics, law, medicine, social sciences, etc., which has specialized in the conduct of the kinds of efforts which are intended to be carried out by the Institute. The Committee, therefore, believes that, if the efforts of the National Institute of Health Care Delivery are to be successful, priorities must be set which will take cognizance of these constraints. For example, the small number of qualified policy analysts leads the Committee to the conclusion that only a few centers of excellence are possible at the outset of the Institute's activities. The Committee also urges that the Institute devote a major share of its effort to the creation of a major intramural health care research effort analagous to the clinical center of the NIH. The Committee also urges the estab lishment within the Institute of a specific unit charged with sup porting and developing training programs and training centers for health policy and health care research workers. The expansion of trained manpower in this area is absolutely essential to the viability of the Institute's long-term program. The Committee further urges that the Institute and the Department of HEW give serious thought to the relationships between the Institute's program and the Lister Hill Center for Biomedical Communications which is located in the Department at the National Library of Medicine. In summary the Committee wishes to stress that the initial years of operation of the Institute will be critical in respect to the longterm success or failure of the Institute, and that the decisions that are taken in respect to the initial year's activities should be made with. the greatest possible care, commonsense, and vision. Finally, the Committee believes it is essential that the legislation establishing the Institute be compatible with those provisions of the HMO legislation, S. 14, particularly the proposed Commission on Quality Health Care Assurance. PRESENT EFFORTS INADEQUATE The present effort in this respect is largely the responsibilty of the National Center for Health Services Research and Development. This Center presently is buried in the Department of Health, Education, and Welfare, being one of many units of the Health Services and Mental Health Administration. The Committee's bill proposes to transfer and upgrade the National Center by transferring it to the new Institute. At its present layer in the Department, the Center lacks visibility and its clout is small. It lacks an effective organizational structure and the flexibility that characterizes many government research and development organizations. It is not funded adequately. It does not even have a real legislative mandate as it operates only under general research authority. Although some interesting efforts have been undertaken at the Center and elsewhere, efforts to date for the most part have contributed disappointingly little either to a solution of the problems of the present. delivery system or to the creation of alternative systems. Important questions raised about health care delivery ten years ago are still being asked today. The Committee is of the opinion that we cannot wait another decade for these answers, not only because of the urgency of these problems, but also because decisions with respect to the directions of health care delivery must be made. To help find the answers to the many health care delivery questions, the Committee believes that research into health care delivery must be made as important as medical research. A new National Institute of Health Care Delivery, with a clear legislative mandate, top management, the necessary organizational structure and administrative provisions, and adequate resources, is needed, in the judgment of the Committee, to achieve this objective. LOCATION AND APPROACH The National Institute of Health Care Delivery will be a separate agency within the Department of Health, Education, and Welfare |