Senator SCHWEIKER. All right. The next panel is Mr. Mott, Mr. Suter, and Ms. Hoskin.

Mr. Mott, do I understand that you are going to present a group statement for everyone?

STATEMENTS OF ANTHONY MOTT, EXECUTIVE DIRECTOR, FINGER LAKES HSA, ROCHESTER, N.Y.; JAMES SUTER, EXECUTIVE DIRECTOR, WEST VIRGINIA HSA, INC., CHARLESTON, W. VA.; AND DOROTHY HOSKIN, CHAIRMAN OF THE GOVERNING BODY, WESTERN COLORADO HSA, GRAND JUNCTION, COLO., A PANEL

Mr. MOTT. Yes, Mr. Chairman.

I am Anthony Mott, the executive director of the Finger Lakes Health Systems Agency of Rochester, N.Y., and also president-elect of the American Health Planning Association. I am joined by two colleagues who will make some comments later on. I will make the basic presentation.

Senator SCHWEIKER. Either pull the mike closer or turn it up. Mr. MOTT. With your permission, we will depart from the text as with the previous witnesses. We have presented extensive testimony which we will be submitting.

Senator SCHWEIKER. Your full statement will be presented in the record, and we appreciate your highlighting the key points.

Mr. MOTT. Thank you.

What we would like to do today, Mr. Chairman, is make some introductory statement from the American Health Planning Association, which is the organization which represents the Health Systems Agency and, more importantly, the roughly 50,000 consumers and providers who serve on the various committees and boards of the HSA's.

Senator SCHWEIKER. And you are president-elect of that group? Mr. MOTT. Yes, I am, sir.

Senator SCHWEIKER. Fine. Go ahead.

Mr. MOTT. It is a great honor for us to be here today in the sense that we recognize that this committee has been instrumental in creating Public Law 93-641. And as we review Senate bill 2410, we see basically a piece of legislation which we think will strengthen the process, will better clarify the situation and put us in a better situation as far as health planning in the country is concerned.

As we have experienced in the last few years of health planning in the country, and the implementation of Public Law 93-641, and as we awaited this particular set of hearings and awaited the review and renewal of Public Law 93-641, we obviously reviewed the initial law and what problems there have been across the lands. As a starting point the AHPA came to a set of conclusions with two basic thrusts. First: we have a set of organizations set up across the land that are up and going and ready to do health planning. It is absolutely critical that we not have renewal legislation at this point that does anything major in terms of restructuring or realinement, anything of that sort to these organizations.

Second, we felt Public Law 93-641 has done an extremely good job of building upon previous planning programs, picking up the good points and eliminating the bad points and starting the work to looking toward implementation.

Again we see in S. 2410 a logical expansion upon this, and we will have specific comments later.

We believe the key to the renewal legislation lies in setting meaningful tasks for the planning agencies, and for evaluating them carefully, both in terms of their public responsiveness, and in terms of the technical quality of the work they do.

We do not operate under any illusions at this point as far as the State and local health planning agencies are concerned. The job that is to be done out there by these agencies, at Federal, State, and local levels, is a very difficult one. It is frequently a misunderstood one, and often an unpopular one, particularly cost containment. I am sure you know, in the abstract, that your constituents or ours, says they are for cost containment. The difficult role all of us have is how do you get from abstract support of cost containment, to the highly specific implementation of this idea. I think we all know the degree of public understanding and support for the specific cost containment activities, thus far.

That is the job HSA's and SHPD's try to do-to build an understanding within our own organizations, and the community, of why things happen, and how we can come up with action plans to create. a change.

The recent controversy over the national cost containment guidelines, which was discussed by the previous witnesses, clearly demonstrates what difficulties can result when the intent of Congress is misrepresented.

The American Health Planning Association fully supported the concept of using quantitatively based guidelines as a benchmark in the planning process, and made suggestions for a local general adjustment process, and for adjustments to specific standards, such as obstetrics, pediatrics, and neonatal intensive care.

It is our conclusion, after reviewing the guidelines, that we do not have quite as much difficulty in ferreting out the intent of the guidelines and standards as some others do.

I would say, as we have reviewed this with people representing health planning agencies across the United States of America, there is a general concensus of strong support for the recent addition of the national guidelines as issued, and for the adjustment process as detailed in it. However, there was, from within the ranks of the health planning agencies themselves, a number of agencies and people who had very deep concerns about the lack of clarity in the original submission of the national guidelines.

It is our feeling that a great deal of good has been done in terms of clarifying this. It is our feeling that indeed it is not only appropriate but necessary that there be benchmarks, that there not be 205 HSA's each trying to come up with their own initial benchmark of how many of few new cancer patients should be there before you move and accelerate controls on radiation therapy. So AHDA accepts them as written, and the concepts behind them.

Having said all that, what we would like to do is quickly go into some of the more important sections of the legislation as written.

I will leave for the moment the whole area of redesignation which Mr. Suter will speak to in a moment. We would like to support the Section 104: Conflict of Interest. This is a very important problem; it is an area that we think needs clarification.

We have offered, within our organizational structure, wording to try to bring about such conflicts of interest clauses within the local area. We clearly support this section.

Another very important feature in the section is section 106, which clarifies substantially the selection process for HSA boards, committees, subcommittees, task forces. This has been an area of lack of clarity. This has been an area of a fair amount of diversity across the land. The intent of section 106 is laudable and appropriate. We have one area of fairly strong concern. As we read section 106, it sets up a very open nonperpetuating process for board selection. This is fine. However, the next step, which is included to require similar procedures to produce a non-self-perpetuating process for the councils underneath the board of directors, gives us problems.

Not only do we not see a need for it philosophically, but it could practically tie up the planning work of the HSA's at the local level.

We strongly endorse the requirement that each agency make their board selection process public, and report this process to the Secretary. We also call upon the Secretary to strenuously enforce clear violations of the principles of broad representation, or failure to implement democratic procedures in board selection.

Section 109 is one we strongly support. We operate completely under all aspects of the sunshine law, there are obviously, as has been seen by the subcommittee, and by staff in preparation of this, areas like personnel records where privacy required are generally beneficial. We support this section.

To go on to section 118, which has to do with certificate of need, which is an area that there has been some discussion today, there are many aspects of this that we strongly support.

We support, under section 118, where there is language in terms of the inclusion within the health plans of descriptive information about the system. We think it is extremely important that these plans describe the system, of what exactly exists out there.

We do think some clarification is needed in the language. There is a statement in there that the plans should not include any reference to specific institutions. We assume this means that the specificity has to come in other iterations of the plan. But we would strongly oppose any provision which denied HSA's ability to collect organizational data on patient origin, utilization, costs and charges by types of service.

The role of the Governor is strengthened in relation to his health plan. We believe that the role of the Governor is important and substantial at this point. We have some concerns with the language of the section.

Our concerns have to do with the problem of the State health plan. Basically, this plan is meant to start at the grass roots, with HSA board providers and consumers spending untold hours putting an individual health systems plan together. The sum of the health systems plans of the separate HSA's in effect became with suitable adjustment the State health plan. A veto, threat of veto or "nonconcurrence" on the part of the Governor, can have a devastating impact on the volunteers who have put the plan together. If they feel they have no real role or responsibility their involvement will flag. We have had examples in my HSA in New York over the last few years where a reversal, when

it did not have to be defended, or negotiated, produced a feeling in volunteers that the process was being violated and their contributions denied. So we would ask for clarification of the language.

We strongly support section 122, which calls for coordination with rate setting organizations.

Senator SCHWEIKER. Going back to the certificate of need, would you comment further on this discussion you heard this morning regarding where we do draw the line in terms of the expansion of certificate of need?

Mr. MOTT. OK.

We do have a little bit further, in here, where we have the certificate, a number of comments on it.

Senator SCHWEIKER. All right, go ahead.

Mr. MOTT. I have to admit, as we observed this morning, we are not in total agreement with the presentation of the previous witnesses on that particular issue, as you might imagine.

Going on to section 129, which has to do with funding, the American Health Planning Association again, in anticipation of renewal legislation has looked extensively at the cost of planning at the local level. We have conducted a fairly major survey on this. The results that we have come up with coincide very closely with the results that are sitting in 129.

Again, with your permission, we will append to our testimony a copy of that particular study, in hopes that it will help.

On one particular area of planning, I will refer to Ms. Hoskin, who will talk about the world and minimally funded agencies.

Section 135, which is the basic certificate of need section, we have a number of areas here that we strongly support. We have a couple of areas where we do have concern. This is part of the section which, in our opinion, weakens the State role in development of certificate of need.

The American Health Planning Association recognized the necessity and desirability of strong and appropriate certificate of need provisions, and is a principal advocate of procedures which would strengthen certificate of need.

Also, it it our feeling that as the section is presently worded, vis-avis "consistent with" may produce a reaction on the part of the States analogous to the reaction to the national guidelines. So we would suggest the present language which requires the State to develop a program "satisfactory to the Secretary" be retained.

Also, we support section 135, the inclusion of a time period for a certificate of need by which it can be reviewed if indeed there has not been any progress. There has been a substantial problem in a number of areas of the country where a needed service is held up because the particular sponsor that has the application approved is not adequate. We support section 137 which requires a uniform format for implementation plans after consultation with the development agencies.

Section 140, we get into that difficult area with reference to earlier speakers, which is consumer and provider. We very strongly support, as a National Association, the intent of this language. There are a significant number of true consumers on the board of directors of hospitals, health centers, or other institutions who have been classified as indirect providers, and frequently cannot get a position on a HSA board because of it.

We applaud any opportunity to get these people seated as consumers, which they truly are. Our concern is, and we have explored this again and again over the last 3 to 4 years, trying to come up with wording that we thought would do that without opening the door to, in effect, including all hospital board members as consumers. We were unable to come up with such wording. In our opinion the wording here will not preclude what the possibility of selecting HSA board members with fiduciary interests in other institutions. For every health center board member we get, we may also get six or seven health members who do have a conflict of interest. Therefore this section should be amended to prevent this possibility or remain unchanged.

Senator SCHWEIKER. Yesterday there was a charge made that some HSA staffs have not always been responsive to consumer needs, is that an accurate representation? Is this a common problem? How serious is that situation?

Mr. MOTT. I do not know definitely how serious. I think it is ending up there there is a responsibility on the Secretary of HEW to monitor, to make sure that it is not existent or widespread.

I can speak from personal experience, that this is not the case. There is no question that there is great difficulty in terms of the motivational aspects of many of the providers to be there, many of them are there of a true sense of here is a law we want to implement for society, many are there because they have interests to protect.

Consumers operate on HSA boards with much different motivations. They frequently have not come into it with the same background. Tremendous jobs have to be done by the HSA's of orienting and involving the consumers so that de facto provider dominant does not occur.

I do not see it as a major problem. I also see it as a situation which, in that line, is improving substantially on a day-to-day basis.

Senator SCHWEIKER. They go a step further and suggest separate staff, or consumer members. Would you subscribe to that?

Mr. MOTT. I would not at all subscribe to it, nor would my association. We see the consumer provider balance in the planning process being absolutely essential. We see the provider, that much of what we are trying to do with or without the clauses in the renewal legislation is going to rely on a kind of voluntary cooperative spirit, and it takes both sides to be there.

The job of the staff of the health systems agencies, backed up by the technical support centers, is indeed to try to bring the consumer and provider together at the table, and get them to an equal position.

It would be, to me, extremely counterproductive to inject staff separate from the health systems agency, to attempt the job of orienting a concern over the provider who needs it just as much.

Senator SCHWEIKER. Another proposal was that the board members' records, financial statements, et cetera, be made public. Do you favor that, and what effect, if any, would that have on the recruitment of board members?

Mr. MOTT. Well, an awful lot of that is public right at this point. Our interpretation of Public Law 93-641 is that there is no information that is not public.

A significant part of what you are talking about, we ask for the disclosure of, so that we can determine whether or not there is a conflict of interest.