- 11 of Congressional priorities when cost containment threatens to reduce the availability of or access to necessary health services. Membership on Governing Boards In a planning process requiring initiative and responsibility at local and state levels, it is important that governing boards broadly represent the community, including its health-related interests. Representation is especially important for medical education institutions. First, as discussed in an earlier section of this testimony, medical education programs rely on and contribute to health service programs. Including a representative from a medical school would help ensure that these interdependencies were recognized and considered in planning decisions. Secondly, as evidenced by health manpower legislation, medical education is increasingly viewed as a national resource. Capitation payments, capitation requirements, and Federal grant incentive programs all demonstrate the national character of medical education. Given the "bottoms up" character of health planning and the increasingly "top down" character of medical manpower development, it is important that planning agencies include on their governing boards individuals who can bring to the board's attention national initiatives requiring local consideration. Thirdly, the medical school is in a unique position to represent health manpower education generally, for it is the medical school faculty that admits the patients who are involved in the training and education of all health science students. Under the present health planning law, HSA governing bodies must include providers who represent "health professional schools." For the reasons stated above, if a health service area includes one or more accredited medical schools, the AAMC strongly recommends that the governing board and executive committee of the HSA be required to include the Dean of at least one medical school as a voting member. Similarly at the state level, in states with one or more accredited medical schools, the AAMC recommends that the SHCC be required to include the Dean of at least one medical school as a voting member. Present requirements for the composition of HSA governing boards also mandate membership for providers who represent health care institutions; however, these governing boards do not have to include direct representatives from hospitals. This is a serious omission. The Health Planning and Resources Development Act relies heavily upon hospitals to achieve its goals. Hospitals are major sources of ambulatory care, emergency services, and definitive inpatient care. Tertiary care/teaching hospitals, moreover, are different from the nation's other hospitals because they also provide: regionalized, tertiary care services to significant numbers of referred patients; medical education programs from undergraduate clinical clerkships to post-graduate fellowships; and the environment for developing and evaluating new medical treatments and techniques. Because of the organizational complexity of the multi-product tertiary care/teaching hospital, it is crucial that the internal dynamics and external interrelationship of these hospitals be specifically included in HSA deliberations and planning. Therefore, the AAMC recommends that HSA governing board and SHCC requirements be changed to require that at leat one member of each body be the chief executive officer of a short-term, general, tertiary care/referral hospital. Mandated Capital Expenditures Each year hospitals make sizable capital expenditures in order to comply with mandatory changes required by various codes, standards, and regulations. Some of these construction and modernization programs require certificate of need approval, others do not. In any case, the magnitude of these expenditures and their impacts on hospital costs is not well documented. If the health - 13 planning program is to have a cost containment objective, as proposed in S. 2410, adequate information is needed on hospital expenditures for mandated capital improvements to ensure that capital planning adequately includes changes in present facilities. Therefore, the AAMC recommends amending S. 2410 to require the Secretary of HEW to undertake or sponsor expenditure and cost-benefit studies of mandated hospital projects resulting from externally imposed life safety, and building codes. A Concluding Concern In the four years since the National Health Planning and Resources Development Act was enacted, many of the organizations required by the Act have been developed and become operational. The structure is in place. If that structure is to be retained, strengthened, and increasingly supported with adequate funding and technical assistance, the next few years should see the planning of planning replaced by health planning itself. At its next renewal, the health planning program should be evaluated on its performance as well as its promise. For such a performance review to be objective and meaningful, criteria for assessing the program's accomplishments and shortcomings need to be established now. Otherwise, the same anecdotes and statistics may be used by program proponents and opponents as justification for continuing or terminating the program. The Association of American Medical Colleges recommends that any legislation extending or revising health planning be accompanied by a Committee Report detailing criteria which will be used to evaluate the program for its continuation. The AAMC would be pleased to work with members of this Subcommittee and its staff to develop and evaluate such criteria for program performance. ASSOCIATION OF FACILITIES 5530 WISCONSIN AVENUE, SUITE 955, WASHINGTON, DC. 20015 TELEPHONE (301) 654-5882 DIRECTOR T. P. Hipkens OFFICERS AND EXECUTIVE COMMITTEE PRESIDENT Theodore Fabyan Cleveland, Ohio PAST PRESIDENT Leonard Weitzman Pittsburgh, Pennsylvania VICE PRESIDENT SECRETARY Dean B. Settle Wichita, Kansas TREASURER Paul F. Wagner, Jr. AT LARGE MEMBERS New York, New York BOARD OF DIRECTORS Russell Albrecht New York, NY. William C. Beck Billings, Montana Robert R. Benedict Lake Worth, Florida Reymond L. Dabney Randall V. Frakes, Ed.D. Paul R. Hoffman, Ed.D. Warm Springs, Georgia Des Moines, Iowa Wham K Nystrom, DPM Walter J. Payne Bernard H Suffel March 13, 1978 Senator Edward M. Kennedy Chairman Subcommittee on Health and Committee on Human Resources Dear Senator Kennedy: This letter is to call to your attention the need for Our primary concern with health planning and resources it fails to recognize that rehabilitation is a distinct, special form of care. 93-641 was enacted to try to introduce a degree of rationality and cost effectiveness into the health care system. As the system which it authorizes evolves it should be comprehensive and cognizant of all elements of the health care system. Final regulations to implement Title XV of 93-641 with respect to health planning were published on January 21, 1977. These do not recognize ambulatory care facilities including outpatient rehabilitation facilities and home health agencies as subject to the health planning process. The Department of Health, Education & Welfare cited "definitional difficulties" as justification for excluding such facilities. As outlined below, we believe there are well established definitions available. We do not believe the issue of coverage of rehabilitation facilities and home health agencies should again be left for determination at the regulatory level and urge that they be specifically recognized by amendment of the law. During the development of regulations to implement 93-641 ARF submitted extensive comments urging the inclusion and recognition of rehabilitation facilities in the health planning and certificate of need processes. We were, and are, concerned that the rehabilitation hospitals and outpatient centers providing rehabilitation services should be included because of the critical need for integration and coordination of services. We are concerned that failure to recognize rehabilitation facilities in the health planning process could lead to proliferation of services, higher costs and less effective services. All of the arguments which support the health planning program authorized by 93-641 apply to medical rehabilitation. We are also concerned about the exclusion of home health agencies. A few of our members operate home care programs and are certified as home health agencies. However, our concern stems from the need to integrate home care services into a continuum of care particularly for people with long term handicapping conditions. To remedy these problems, we recommend that several changes be made in P.L. 93-641, and in the proposed amendments outlined in S. 2410 as follows: Amendments to P.L. 93-641 (Not addressed in S.2410) The existing composition of the membership of |