B.

In facing the serious challenges of P.L. 93-641, the foregoing group has had to struggle not only with problems indigenous to their areas, conflicting and confusing Department of Health, Education, and Welfare regulations, performance standards criteria and guidelines, but also a

serious and crippling lack of adequate funding. Furthermore, many of these Agencies serve sparsely populated and immense geographic areas, often with rugged terrain, adverse weather and limited transportation networks.

Congress has mandated enormous responsibilities for all Health Systems
Agencies throughout the country, regardless of their size. However,
current funding, which is based primarily on a per capita dollar formula,
often penalizes smaller Agencies in meeting the health needs of their
residents. Notwithstanding the challenges faced, these Agencies have
had notable successes, not only in meeting Federal Guidelines and
expectations, but also community needs, in the short timeframe of less
than two years.

A. A listing of activities mandated by Congress which each Health Systems Agency is required to perform is found in Attachment 1. This list also includes performance standards and expectation levels developed by the Department of Health, Education, and Welfare as a basis for measuring Agency compliance.

It is apparent from this list of activities that the responsibilities of all Health Systems Agencies are enormous. Where this affects the small, minimally funded, and rural Agencies to a greater extent is in the capacity to meet these standards with limited staff and resources.

Results of a survey recently taken with respect to the needs of these Agencies in meeting the above standards have clearly indicated that, under current funding levels, most of these Agencies do not have more than five professional and two clerical staff. The Bureau of Health Planning and Resources Development (BHPRD) currently requires Agencies to maintain records and activities in seven distinct functional areas:

B.

Data Management

Coordination

Public Involvement

Most Agencies surveyed estimate that, in order to adequately meet current

expectations, a minimum or average of one staff member per function is an Further, many feel that additional staff is

absolute prerequisite.

necessary to comply with local needs and demands.

It should be noted that Congress has established a minimal funding level of $175,000 in P.L. 93-641 to accomplish all of these tasks.

Unfortunately,

the Department of Health, Education, and Welfare interpretation has, for the most part, concluded that this is the maximum funding level for many of the Agencies previously listed.

The group asks that the Federal funding level be at least 70¢ per capita with a minimum of $275,000, including a provision for inflation. Further, the group feels that the Secretary of the Department of Health, Education, and Welfare should be given 5% of the arppropriation made under this Act for discretionary use. The Secretary would then have the ability to meet the needs of those Agencies which have extraordinary travel expenses caused by large geographic areas and/or sparse or widely distributed population; energy, or other growth impacts; multiple jurisdictions such as two state agencies or SHCCs; and other problems.

North and

The Agencies presenting this testimony extend across the Nation
South, East and West. Many face, as previously indicated, enormous
distances, sparse population, difficult terrain, and significant adverse
weather conditions. Public Law 93-641 demands public involvement of
consumers and providers who are residents of the area in planning for
their health. For issues to be discussed and resolved in a democratic

manner, adequate provision must be made for insuring participation,
involvement, and accountability by and with Health Service Area residents.
From the survey, many of the small Agencies spend in excess of 10% of
their total budgets on Board, Committee, and Staff travel.

Examples:

The Western Colorado Health Systems Agency spent $21,150.00 for
travel in FY 1976-77 and was only fully staffed and operational
for approximately nine months. This amount represented 14.6% of
its $145,000 Budget. For FY 1977-78, its travel budget is
projected at $29,500 or 16.9% of $175,000 allocated. Travel costs
per meeting range from $650.00 to $1,200.00, depending on location
and exclusive of overnight lodging.

The Health Planning Association of Western Kansas (HAWK) spends
in excess of $25,000 per year for the travel of its Board and
six Subarea Councils to cover its 46,000 square mile area.
Involvement includes 57 Board Members meeting monthly and 210
Subarea Council members meeting bi-monthly.

Involving the public in crucial health planning decisions is, perhaps,
one of the few rational approaches to overall cost containment for health
services. Comparing Agencies covering 40,000 square miles and spending
fifteen percent of their budget on travel with those of 400 square miles
and spending less than five percent, is a major point that Congress should
review and consider as part of these Oversight Hearings.

III. RURAL PROBLEMS

A. Previous Congressional Reports such as The Economic and Social Condition

Federal

of Rural America in the 1970's (prepared by the U. S. Department of
Agriculture, December 1971) have found that rural Americans do not share
proportionately in programs funded by the Federal Government.
spending on Human Resource Development (Health, Education, Welfare,
Vocational Rehabilitation, Manpower Training and Development) favors
metropolitan counties over rural areas.

Examples:

-per capita outlays under conditions of pronounced population
decline for health services are 4 times greater welfare
payments 4 times greater manpower training and development
3 times greater

in metropolitan counties than in rural ones;

-rural counties account for 66% of all substandard housing units
but receive only 16% of all Federal housing assistance;

24% of Federal aid to

26% of Federal headstart and

-rural counties account for 50% of all children between the ages of
6 and 17 in poverty level families, but receive only 20% of all
Federal child welfare service funds
families with dependent children
followthrough assistance; and 41% of Federal outlays for
elementary and secondary educational programs aimed at meeting the
specific needs of disadvantaged children in low income areas.

The entire history of Federal support for local regional health planning
has been one of underfunding for rural areas. While 27% of all Americans
live in rural areas, only 15 to 20% of health planning monies go into
rural areas. Comprehensive health planning for rural areas, if accomp-
lished previously, tended to be done by state departments rather than by
areawide rural health planning agencies.

Although the present health planning legislation provides for total geographical coverage by Health Systems Agencies with a minimum funding level of $175,000 for less populous Agencies, we suggest that health

B.

planning in rural areas remains underfunded.

A large part of the work

of the rural Health Systems Agency is in the Plan Implementation/Resources

Development function, in addition to being concerned with cost containment issues relating to inappropriate service development.

This commitment to resource development should be evident from the correlation between "Critical Health Manpower Shortage Areas" (CHMSA) and "Medical Underserved Areas" (MUA) and the areas covered by rural Health Systems Agencies. Furthermore, the need for making health services

more available and accessible in rural areas has been recognized by Congress, as evidenced by item (1) of the National Health Priorities of

P.L. 93-641"

Sec. 1502. The Congress finds that the following deserve
priority consideration in the formulation of national health
planning goals and in the development and operation of Federal,
State, and area health planning and resources development programs:

(1) The provision of primary care services for medically
underserved populations, especially those which are located
in rural or economically depressed areas.

Increasing the minimum funding base for rural Health Systems Agencies will
not only strengthen the implementation of P.L. 93-641 in approximately
40% of the Nation, but will help ensure the most effective and efficient
utilization of health resources. Adequate financial support is essential
for effective rural health planning, and effective rural health planning
is a requisite for assuring that health care services are available,
accessible, and acceptable for all residents of rural areas.

Historically, Federal approaches to health problems have been categorical;

most programs have focused on individual groups or populations with specific problems or diseases. While we understand there are complex pros and cons concerning categorical programs versus block formula grants or the revenue sharing approach, the dominance of categorical programs places a great burden on Health Systems Agencies, especially minimally funded Agencies with few staff resources.

Although P.L. 93-641 was very successful in consolidating the Regional Medical Programs, Comprehensive Health Planning and Experimental Health Service Delivery Systems, there still remains fragmentation of health planning efforts in most Health Service Areas.

Planning for implementation

of Emergency Medical Service is an example. The insulation of the

26-219 O 78 pt. 2 - 16

IV.

Veterans Administration and their own internal planning is another.
Furthermore, there are many state efforts (often with Federal support)
that also fragment health planning in rural areas.

More recognition and support on the part of all Departments and Programs of the Federal and State governments could go a long way to assist rural health planning agencies in acquiring the critical mass necessary to accomplish their planning and development responsibilities.

C. There are great difficulties for rural Health Systems Agencies in developing an adequate data base. There are a number of factors contributing to this problem such as the present legal restrictions on the collecting of primary data in the absence of assistance from other sources. Rural Health Systems Agencies generally are dependent upon data supplied by health care providers, such as small rural hospitals who may not keep records on such items as discharge diagnosis. However, in cases where they do, such data. are often not uniform with other facilities in the area. In addition, Health Systems Agencies are held accountable for cost containment but Federal and State governments are often restricted in disclosing financial information that is routinely provided by health care provider groups.

D. Another concern of the rural Health Systems Agencies are the recently proposed and revised Department of Health, Education, and Welfare Guidelines for Health Planning. This group maintains that the need exists for a balanced approach which includes strong health planning, appropriate health service development, and regulation.

The group supports active participation in the development of cost containment strategies that accurately reflect the unique needs of their Health Service Area residents. It should be recognized that the Guidelines are useful in establishing debate and focusing concern on necessary cost containment initiatives. It should be remembered that the Guidelines are, in fact, only experimental estimates which serve as guidance not law.

RURAL HEALTH PLANNING SUCCESSES

A. Despite the problems, limitations, and constraints under which rural Health Systems Agencies must operate, they have experienced some rather significant successes. Below are examples of the positive experiences of