III. Involving the public in crucial health planning decisions is, perhaps RURAL PROBLEMS A. Previous Congressional Reports such as The Economic and Social Condition of Rural America in the 1970's (prepared by the United States (Education, Health, Welfare, Vocational Rehabilitation, Manpower Training and Development) favors metropolitan counties over rural areas. Examples are as follows: per capita outlays under conditions of pronounced population - rural counties account for 66% of all substandard - rural counties account for 50% of all children between the The entire history of Federal support for local regional health planning be done by the State agency rather than by an areawide rural health planning agency. Although the present health planning legislation provides for total geographical coverage by Health Systems Agencies and a minimum funding level of $175,000 for less populous agencies, we suggest that health 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 some 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 B. 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 "(1) The provision of primary care services for medically " Because of the added challenge of resource development (in addition to other problems noted previously), we submit that rural Health Systems Agencies should be funded higher than urban areas. This proposition is as reasonable and logical as understanding that per capita public assistance payments (and many other Federal spending programs) will always be higher in urban areas and attempting a rural-urban equalization for income maintenance (and many other programs) would not be feasible. 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 area of the Nation, but it will help to provide necessary resources to planning agencies attempting to ensure the most effective and efficient utilization of resources. Adequate financial support is essential for effective rural health planning which 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 or special beneficiary status. While we understand there are complex pros and cons concerning categorical programs vs. block formula grants and 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. Health Systems Agency staff must become familiar with hundreds of programs and dozens of personnel in several departments in order to plan and develop resources consistent with legal and other constraints within which these programs must operate. Again, the rural Health Systems Agencies require additional resources in order to relate properly and effectively with Public Health Service Program Chiefs to assu assure that the allocation of Federal categorical funds are consistent with the Health Systems Plans (HSPs) of Health Systems Agencies. The establishment of these important relationships are obviously more difficult for agencies with severely limited staff resources. C. Although P.L. 93-641 was very successful in consolidating the Regional Medical Programs, Comprehensive Health Planning and Health Service Demonstration Projects, 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 Federal Veterans Administration and their own internal planning is another. Furthermore, there are many state efforts (often with Federal support) that further fragment health planning in rural areas. D. 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. 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. Among them are insufficient assistance IV. from the Department of Health, Education, and Welfare and most State Health Departments and State Health Planning Department Agencies with present legal restrictions on the collection of primary data in the absence of assistance from other sources. Rural Health Systems Agencies are also dependent upon data from health care providers, such as small rural hospitals, who often do not keep records on such items as discharge diagnosis or, in cases where they do, they are often not uniform with other hospitals in the area. In addition, Health Systems Agencies are held accountable for cost containment but the Federal and State Governments do not disclose or provide adequate financial information that is routinely provided by health care provider groups. E. Another concern of the rural Health Systems Agencies are the recently The group supports active participation in the development of cost RURAL HEALTH PLANNING SUCCESSES A. Despite the problems, limitations, and constraints under which rural Health Systems Agencies must operate, they have experienced some rather |