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MEN FORA AIND UM DEPARTMENT OF HEALTH, RDOUCATION, AND WELFARE

PUBLIC HEALTH Se RVICE
HEALTIT SERVICES AND MENTAL HEALTH ADMINISTRATION

Assistant Secretary for Health
TO : and Scientific Affairs DATE: .

Attention: Denuty Assistant Secretary .
for Pols icy | jovi elomment

FROM =: Administrator, HS

CURIECT= rien + ~ . ”
SUBJECT: BVP Issue Paper (Cetober 12th) and the Secretary's Decision
on RMP and Health Reverme Sharing

4

The RMP issue document is a conscien

future direction of the program. oy, in light cf the Secretary's
specay ul health revenue sharing,

ue be revised in such a way as

aury's decision regarding RMP and

‘jous effort to analyze the
Ove}
Gg

  

recent decision to jncorparc re
we believe that the issve document s
to constitute an appeal to the Secre
special healih revenue sharing.

 

a

« the introduction to the issue
constitutes en appeal to the

- j would also s st that the
! uctoery statement incline much ¢ * the substance of “my August 10
memorandun to you concerning RMP as a provider constituency.

   
   
  

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The organization of the material in the remainder of the issue docunent
creates the erromcous impression thet these issues exist side by side
so that decisions can be made on one issue without adversely affecting
the ranee of options that are ava: subsequent issues. Obviously,
this circunst is not the case. ues are related sequentially.
Conse. 5 cisions made on one the subsequent issucs. More-
over, the sequence of issues is not lowical. The future mission ‘of RMP
and the Chip + ole in approving of Rep proposals for the entire
ba
th

 

 

   
  

    

    
   

“Oo
RMP programs are sically the questions that should be addressed
initially since ~ Nerd purposes", Other issues such as
décentralization, fund and local RvP organization, have meaning
only once "ends" are decided upon. 1 ther efore suggest that issues
(1) and (7) be set into a Part A of the document to “be decided upon
before the other issues which I sugsest should be grouped into a Part B,
receive attention at all. re

   

With respect to the particular issues we have the following comments:

Issue I: The Mission of RMP

No purpose is served by eliminating the program or confining its
activity to control pregrans. ‘Therefore, I opt for options within
Page 2 - Assistant Secretary for Health
and Scientific Affairs

Issue I that permit RMP to continue to scrve as a mechanism between

the public sector and the private health provider which undertakes any
or all issues within that cormmity that have been identified as needing
attention by the provider comminity. Maximum flexibility in program
initiative responsibility has to reside within the local provide
comunity if we are in fact to achieve a pechantsn | that conmmicates
between the public sector and the private | sealth providers in the field.
This is what RWP is uniquely able to do. Therefore we support those
options within this issue that allow RMP to do this without in any way
delimiting its role, This would include options <, 4, and 5. The
rationale for this recommendation would be that RMP would remain the
unique national commmications network with providers through which

HEW can bring leverage to implement change. A flex sible role is necessary
if it is to carry out nationel pricritics within the context of local
needs. A drastic change at this time in N?'s authority or orgenizational
structure would 3 cde the progress we have made with the health care
providers. At the same tine that the authority remains flexible, in-
creased emphesis cen be given to Ri's role with respect to the closely
related issues of manpower util productivity and quality
assurance. PMP can be an effective technical assistance cool in the
quality assurance area and use an cm on manpower utilization a and
productivity to assure the implementation of quality assurance programs.

   
 

 

 

   
   

  
   

 

 

sant pary
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Issue VII: Relationship to Cup . .

The RMP program needs to be better tied to the CEP review process,
particulcrly in Ligt of the view that t this is a local program. Our
preference would be to have the Ruy grent be subject t to the CHP review

and coment and heave CHP epprevel of cbicctives of the grant rather then
have thon undertake the review and comment on specific activities proposed
for within the or The exception to that rule would be that CHP

should have revicw rove vor pes activities included within

the REP prograa whi result in construction of
facilities, pure! wip ve, payment for direct services,
or other direct impacts on the 3 delivery of services to people within the
area. ‘The RMP erentce shoulda be held responsible to assure thet the
specific projects and activities funded throuch the RMP grant remain
consistent with the RMP program which should have been clea ured with a

CHP agency. os

 

   
      
  

   

 

commend a new option, 3, which would provide
for review “and approvat by CH? on these KP projects related to health
care delivery systems improvenent in the con “sunity, end for review and
comment, but not veto authority on those iP projects. which are prim imarily
develogental in-nature, such as quality assurance activities, research

In light of this, I would re

 
   
  
Page 3 - Assistant Secretary for Health
and Scientific Affairs

and development effort and general core support. ‘The rationale for
this recommendation would be that CHP should have approval authority
over those projects which impact on the health care delivery system
which is thoir primary concern. However, other projects which have
a more generic nature and represent a teronstration or testing of
approaches which might have more national rather than local
applicability should not be subject to CHP veto authority. At the
same time, the CHP should be given the authority to determine which
projects fall into one or the other category. ‘

Other Issue
Questions of decentralizaticn and the methods of funding are really
process issues. However, if you embrace the thesis that RMP is a
device for us to communicate with the local provider conmmity, then
it ought to be basically constituted as providers with an advisory
consumer activity. ‘The funding mechanism which T feel most comfortable
with would be en allowance to support the mechanism as a mechanism,
with the ebility <o provide addit al wenies insofar as the local
program rexlects soine nationally designated priorities. Special ear-
marks might be attached to reward RuP's which pursue special nationa
goals.

 
   

Therefore on Issue II concerning decentralization of authority, we.
would recommend option 4 which would allow for determining national
objectives at the Federal level, assigning CHP responsibility for
determining the degree to which national objectives are being met in

the verious states, and assign to RMP a major implomenting responsibility
for realizing national objectives jn eccordance with CHP determination
of relative needs. The rationale for tnis is that it is consistent with

 

 

the position that RiP's represent the Department's principal communication
mechanism with providers, end at the sore time it clearly points up the

relationship between RMP and CHE and is consistent with the separation
of planning and jmplementing authorities.

With respect to Issue IIT cn how funds should be apportioned to local
RMP's, we would recomnend option 6, i.e. using a combination formula-
competitive basis. The rationale is that this option provides the best
balance for Gistribution of funds. The formula basis would be used to
provide the core support for RMP's, while the competitive basis should
be on a program rather than a project basis for national funds. At the
same time the projects proposed by RMP's would be subject to review by
CHP's for consistency with local planning objectives and priorities.
Page 4 - Assistant Secretary for Health
and Scientific Affairs

With respect to Issue IV regarding categories of people to be represented
on the board, we would recommend option S$ to include providers and public

representatives. The rationale is that nis is essentially the existing
pattern in most RMP's and gives recornition to the basic philosophy that
the RMP's do represent the provider anu of the implementing a authorities.
To specify too many particular catesorics of representation on the board
makes too inflexible a requirement. However, by stipulating that other
than providers must be on the board using the broad term "public" assures
that there eve nonproviders in the decision-making capacity.

With respect to Issue V concerning requirements for consumer participation,
we would recowsend option 1, allowing for 20% participation. The. 20%
figure is consistent with the direction in which most RMP's are now moving.
To increase it beyond 20% as a minizam requirement would compromise our
position with the providers. However, a minimum requirement will assure
that consumers are represented in the decision-making role.

 
  

 

 

On Issue Vi rez:
option 2 ta ve
proposed p:
Alternative!

 

 

nul rings on _ activities, we would reconmend
re Dlg. to hold 7 pee carings on general objectives for
but not with respect to “wards for individual projects.

id consisten t with - the Secretary's decision on the
inplementing ney under special -alth revenue sharing, the public

hea rings could be held by CHP on pup projects, rather than held by RMP
itself, In auy case, public hearin:s promote accounta bility on the part
of the RMP anc makes the role of RP more visible and therefore it should
be a requir t. Powever, it shovld relate to the gencral outline of
proposed prograns rather than a preject by projec t basis since most of the
projects may be of a technical nature and not subject to clarification
through public hearings. Review of indivicusl projects, particularly
these relating to heaith care delivery systems, 1 would be subject to review
and comment by the local. CP agencies and their related hearings processes.

      
 
  

  

     
   

We would appreciate the opportunity to review the next draft of this
peper, particulariy in lignt of its use as an appeal to the Secretary's
decision on sneciel health revenue shuring. If you have any questions
about our coments, please contact Mr. Gerald Riso or Ms. Beverlee Myers. |

On.
fred brick, oS JXepe

Vernon i