"The result of the workshop for me was very satisfactory...since our HSA was organized to use subarea councils, I feel this approach was well oriented...the workshop was good in helping establish relational aspects." --Subarea Council Chairperson (Kentucky)

"Our corporation is very appreciative of the support and technical assistance available through [Health Planning Center] it is our opinion that your broad knowledge of the field and contacts with multi-disciplinary consultants is a real advantage to the southeastern region HSAs."

--HSA Director (Florida)

"Basic planning techniques will be useful in all planning, not just behavioral." --HSA Planner (California)

"The review workshop surveyed the available information at just the right time..."

--HSA Plan Implementation Director
(Oregon)

"Consultation document is a very good instrument to encourage a common planning approach throughout the state."

--HSA Director (Alaska)

"The long-range value of [the Center for Health Planning] is in their
ability to assist agencies to develop greater planning capabilities, and to
provide short- and long-range planning expertise to areawide and other
state programs. I believe the concept of centers for health planning has a
great deal of merit and should be continued for the purpose of successfully
implementing P.L. 93-641."

--SHPDA Staff Member (Wyoming)

"You proved again what a valuable resource the [Center] and its staff can be to a health systems agency. We appreciate your presentations, and equally most helpful response to many questions."

--HSA Director (Illinois)

"We felt the entire session was received very well as evidenced in the stimulating question and answer period which continued well beyond the plan session end. Many comments have been received from board members indicating their satisfaction with the information discussed that evening, even as a review for those already familiar with the issues."

--HSA Chairperson (Minnesota)

"The Center is doing an excellent job. If our agency were to review your renewal contract, recommendation would be approval. The staff have attended seven meetings presented by the Center and all reports have been excellent." --HSA Director (Ohio)

Mr. ROGERS. Dr. Carter?

Mr. CARTER. Thank you, Mr. Chairman.

Dr. Kimmey, you are involved in health planning. Is that correct? Dr. KIMMEY. That is correct.

Mr. CARTER. Do you believe in a regional concept of health delivery?

Dr. KIMMEY. I think that planning on a regional basis, as it has been embodied in this particular legislation, certainly has a number of advantages in terms of the very things the legislation set out to do, allocating resources on a regional basis, making sure services reach those who live in that region and that there are not excess services.

Mr. CARTER. Enough but not too much-so it is cost effective and yet does deliver health services as needed. Are you having many difficulties, now, with your health planning and your teaching? 1 notice you are teaching health planning, too.

Dr. KIMMEY. In our region, I work in the States of Minnesota, Wisconsin, Illinois, Ohio, and Kentucky, and we have 42 HSA clients. Of those, 11 are minimally funded HSA's. They have a minimum budget possible under the legislation.

We have offered, since we started in July of 1976, 32 courses for these folks, and in our particular case, over 1,400 people have attended these courses. Some of them have been directors and board members, some State staff members.

For the most part, we find that the people that come to the training courses are satisfied, that they get something that is useful to take back to their jobs.

When we have gone in 6 months later and asked again questions about the specific course content, again, they have indicated some of the things they have learned in these courses have been put into effect in their agencies. I would say we don't feel we are having a great deal of difficulty in this. Our greatest problem is reaching everybody that needs to be reached. There are 1,500 people on the boards of these agencies. We are only beginning to touch the need. Mr. CARTER. Could you give a brief description of health services that could be offered in an ideal region?

Dr. KIMMEY. Well, if you are looking at direct services we would like to see offered, I think that first and foremost, there are two things that have to be there before you build the rest-adequate primary care services for all, and an adequate health care system. Mr. CARTER. What do you include in primary care?

Dr. KIMMEY. I would include general practice, general medicine, long-term care within easy reach of the people that need it, including nursing home care.

I think that one of the problems in the whole regionalization issue. is that we have not developed a good, useable, widely applied classification of services. You asked me my definition of primary care, and I would go on to define secondary and tertiary. I think we need to look at those fields together, so that a person that comes into contact with the system in a primary care setting gets access to all levels of service in an orderly fashion.

Mr. CARTER. Would you describe some of the secondary services?

Dr. KIMMEY. In secondary care types of services we would find more complicated types of specialty surgery, for example, the handling of complicated obstetrics.

Mr. CARTER. What do you mean by complicated obstetrics ?

Dr. KIMMEY. Any woman who is identified as a high-risk mother, for example, or who may require a caesarean.

Mr. CARTER. What about a breech presentation ?

Dr. KIMMEY. No. I think a breech presentation is a complicated obstetrical problem, but well within the reach of a primary obstetrician.

Mr. CARTER. You think that would come under primary care. What about a footling breech presentation?

Dr. KIMMEY. My experience is limited. We never know those were coming until they got here.

Mr. CARTER. Both of those are rather difficult, it seems to me they would come, certainly, under secondary care. The single footling breech mortality is quite high.

Dr. KIMMEY. I don't disagree. What I was trying to express is how you might classify the services rather than the cases in the system by complexity. I certainly agree that is a complicated obstetrical problem.

Mr. CARTER. You would still put it under the primary care. Caesarean sections-where do they come in?

Dr. KIMMEY. That can be done by a primary care obstetrician, as opposed to being referred to referral centers miles away.

Mr. CARTER. What about a ruptured uterus-what are you going to do with her?

Dr. KIMMEY. I would send for a mobile intensive care unit. I hope I am close enough to get one.

Mr. CARTER. I assure you we have got to take care of such things. What do you consider tertiary care?

Dr. KIMMEY. Tertiary care are those things that are of a relatively low requirement within the population to be served by the tertiary facility, such as highly specialized things like open heart surgery, complicated diagnostic medical problems, the things that need the full scope of modern scientific medicine.

Mr. CARTER. Cardiac inferrings-would you include that?

Dr. KIMMEY. No; I think coronary intensive care units can be adequately operated at the secondary level.

Mr. CARTER. Well. Thank you very kindly.

Mr. ROGERS. Let me just say, if you would furnish for the record, any suggestions you would have regarding changes in the law required to improve the provisions which would be of technical assistance to HSA I think that would be helpful.

Dr. KIMMEY. We would be happy to do that.

Mr. ROGERS. There is a vote. The committee stands in recess for 10 minutes.

[Brief recess. ]

Mr. WALGREN [presiding]. We will resume.

Dr. Carter will be with us shortly.

We welcome, now, a panel of health systems agency representatives and State agency representatives, Mrs. Dorothy Hoskin, presi

dent of the board of Western Colorado Health Systems Agency, along with Mr. Dave Meyer, the executive director of Western Colorado HSA, and Col. Bertram Parr, vice president of the board, Health Planning Council of the Eastern Shore, of Maryland, accompanied by Mr. Fred Dierks, executive director of the Health Planning Council of the Eastern Shore, and Mr. Richard Neibaur, president of the National Association of Single State Agencies.

We are pleased you are here, and we would like to give you the opportunity to go forward with your statements in whatever way you like.

The written statements will be made part of the record. You may summarize them or read them as you see fit.

STATEMENTS OF DOROTHY HOSKIN, PRESIDENT, WESTERN COLORADO HEALTH SYSTEMS AGENCY, INC., ACCOMPANIED BY DAVE MEYER, EXECUTIVE DIRECTOR; COL. BERTRAM PARR (USA RET.), VICE PRESIDENT, HEALTH PLANNING COUNCIL OF THE EASTERN SHORE, INC., ACCOMPANIED BY FRED DIERKS, EXECUTIVE DIRECTOR; AND RICHARD NEIBAUR, CHAIRMAN, NATIONAL ASSOCIATION OF SINGLE STATE AGENCIES

Ms. HOSKINS. Thank you.

I am Dorothy Hoskin, and we, today, represent 36 health systems agencies from across the country and these agencies have two things in common. First of all, they are minimally funded, which, under the law, means that they got the bottom line funding and they are mostly rural.

Unfortunately, the marriage of these two characteristics is often rather rocky. We have expended our meager funds to be here today to urge you, first of all, to please continue Public Law 93-641 basically intact. We feel it is a good law. It is doing exciting things in our areas. For example, we are finally planning for ourselves, which was not the case in the past.

Now, speaking directly to section 206 of your amendments, the topic of that section is funding, our primary problem is money, or shall I say, the lack of money. We urge you to increase the minimum funding level for HSA's to $275,000, 70 cents per capita, with an inflation factor. We feel very strongly that we must get community participation in our planning process. When we are talking about a rural HSA, we are talking about communities that are 400 miles. apart. Therefore, one of our primary costs is travel.

For example, one of our board meetings in one corner of our area cost $1,200 just for the expenses. Most of these agencies are spending 10 to 15 percent of their budgets on travel. We also represent areas that historically have been medically unserved. They were not funded at the same level as CHP agencies, for example, therefore, the planning efforts are just now getting started. We do not have a historical record.

Now, the national push seems to be for costs containment. We hear that from many directions, but we have difficulty with it because our residents do not have primary care. In other words, it is not

available or accessible. What we need is creative resource development. We don't need to worry about cutting costs, because we are not spending because we don't have those particular things available in our areas. We figure that in order to do the job outlined, first of all in the law, and second of all as that law is interpreted by HEW, it would take at least seven professional staff people with support.

In our written testimony, we have included four pages that merely list the tasks that are required, in case you wondered what we have to do, you may refer to that. That will explain the enormous job that all of us have to do no matter whether we are big or little. We are complying but our five staff professionals are working 60 to 70 hours a week. This can't go on forever. Staff will burn out. Our salary levels are much lower than the larger agencies can offer. Therefore, we lose a staff person, we are really in trouble.

We would also like to point out that the legislation uses the word, minimum funding. I don't exactly know what the intent of Congress was, but I assume when they use minimum, that would mean that was the least amount we could get. You did not use the word maximum, however the HEW does use the word, maximum, on the same figure you call minimum.

Also, there was some supplemental funds given out in the last year, and they were appropriated on a per capita basis. Whenever you talk about per capita, we never see it. There is a certain problem in giving discretionary funds to HEW. I shudder when I think about what they might make us do to prove that we need those funds. Just to put together our grant application yearly costs 2 man months of work. In other words, we spend a lot of time on paper work and I fear that proving discretionary funds might also cost more staff time.

We urge you to give us enough to do the job properly and then let us do it.

Now, since we got together and did our analysis on what we honestly felt it would take to do the job, there has been a bill introduced in Congress, 10460. We studied these amendments. We have different feelings on the particulars, but if you go through and look at them and figure out what it would cost, because we are thinking about money, it would cost at least two additional professional staff because of the added responsibilities which would add about $50,000 to what we would need to do the job. In other words, we got together and said, we can live with $275,000, if they don't add anything, but if they add other things, we are still in trouble.

Now, I would like to speak specifically to one more section in the proposed amendments. That is section 223, which has to do with statewide health coordinating councils. While most of the proposals would strengthen Public Law 93-541, we violently oppose this particular one because we feel it does not strengthen the law at all. It speaks to HSA representation on the statewide health coordinating councils. It proposes that the representation be proportional to the population of the agency. This simply means that the large agencies in any State are going to control the ship. If we are going to have local planning, lets have local planning, lets let it work. Don't make the SHCC so overpoweringly urban that we are faced with urban