wouuau ISSUE PAPER REGIONAL MEDICAL PROGRAMS October 19, 1972 See a eee ee mene we ee ee see rt ee UND LaWLROIAAULN OU NE OFFICE. EOF THE SEP PEARY be dy Vi CO oo. . i | . Hi ’ ne i Nee | tf ootget 19, 1972 e TO : The Secretary Through OS/ES FROM : Assistant Secretary for Health and Scientific Affairs . . SUBJECT: Decisions on Regional Medical Programs - . ACTION MEMORANDUM This Action Memorandum develops alternatives for the future of RMPs and related RMP issues. It is supported’ by a Summary Memorandum (Tab A), and by considerable background material under Tab B. ISSUES AND OPTIONS . , : A . MISSION ISSUE I. WHAT SHOULD BE THE PRIORITY FUTURE MISSION (ROLE) OF RMP? OPTION 1. RMP should become a principal agency res- ponsible for imolementing change in local delivery system (implementing agencies for CHP and other HSMEA comvonents, NIH, etc.). DISCUSSION Elimination of restri ictions eon interference with prac- tica of medicine and of categorical emphasis are neces- so ots 44 wee -- be 7 27 TS * Sot be ey 1 ‘@) Sar, LO Calta (eel bon ae Page 2 ~ The Secretary Clearly separates planning from imple~ mentation. , Consistent with HSMHA's mission in delivery reform. Gives it specificity without unnecessary restriction. Has been successful in the past in impleé- menting role. Makes it hard to evaluate. Difficult to provide Federal direction. Proposal to eliminate categorical emphasis and restriction against "interference" with medical practice would be unpopular with AMA and other lobbying groups. O t. 5. 6.6. ‘7. 8. OPTION 2. \. Set” Dependent upon emergence of an effective local planning process. ~ Would impose an untested responsibility on RMPs in terms of relationship to CHP agencies. Lack of broad representation on Board. RMP has shown little interest in preventive . health issues. RMP has shown little interest in maternal and child health issues. RMP shoul@ continue as is -~ flexible, variable, broad: authority which encourages providers to own initiative to brine about chance they sup7 Page 3 - The Secretary PRO: 1. Consistent with Departmental and HEW/HSMHA philosophy of decentralization and local initiative. 2. Allows flexibilities so that the procram'.is able to meet local needs in a local manner. 3. Maintains flexibility for responding to changing national priorities. 4. Consistent with past practice which has achieved considerable professional and Congressional support. CON: 1. May not be highly responsive to HEW priorities. 2. Evaluation is more complex when the program is investing in a variety of activiries. 3. Provides Federal support for some projects and reforms for which providers ‘should bear the cost (e.g., continuing education of physicians). 4, No measurable nationwide effect. OPTION 3. RMP should restrict its activities to "cate- . gorical areas" (heart, cancer, stroke, kidney). PRO: 1. Political and professional constituency easy to identify and highly supportive. 2. Easier to account for expenditures: 3. Provides opportunity for working relationship between NIH research and control programs, and the HSMHA focus on delivery activities. CON: 1. Tends to fragment delivery system ~- obstruct efforts to improve access. 2 lw position on limiting anas to molving orcklems. fy s3 gas ct ae © funding % sith NI. OPTION 4. RMP should emphasize improving the utili- zation and productivity of manpower. PRO: 1. Consistent with HEW philosophy of cost con- tainment and delivery reform. ¢ . . 2. Progress in this area cannot be achieved without the input and involvement of pro- 3. Encourages a closer relationship between the production of health manpower and their actual performance or utilization, i.e., relationship between education and health services delivery. “CON: 1. Could be done well only with _a consistent Federal health manpower strategy. Otherwise might produce scattered, inconsistent activities. 2. Creates resistance from educational insti- tutions which regard this as their area of responsibility. 3. Creates bureaucratic turf problems a la AHEC's. 4. Proposed emphasis on "productivity" raises the question of whether we really know enough to accomplish this, and if we do, can we really capi- talize on it -- manipulate the system enough to use it. # OPTION 5. RMP should,become the agencv responsible for aiding local areups to organize and audit review activities aimed at assessing and assuring quality of care throughout the countrv. influenced by amar ER. 1, Page 5 - The Secretary PRO: 1. Necessary to develop mechanisms for mea- suring quality that are workable and acceptable to providers and the community. 2. Nenecsaryv tn provide corrective action in response to deficiencies identified by quality monitoring. 3. Only provider influenced groups will be ef- fective in this area. 4. Efforts to develop peer review mechanisms require extensive resources and technical assistance to raise the level of understanding of quality monitoring, and start initial development at the State or community level. 5. National interest in developing quality as- surance activities. 6. ° National need for technical assistance in © quality assurance. 7. Consistent with professional interest in many RMP groups and staff. CON: 1. Difficult to measure results. 2. The costs of this effort might better be borne by provider groups than HEW. 3. Local PSRO groups may not accept RMP in- volvement. | 4. Many RMP's may resist assignment. x OPTION 6. RMP should become asency resronsible for - monitoring quality of care. O Page 6 - The Secretary PRO: 1. Federal need to take more positive leader- ship to provide an alternative to or im- plement PSROs and quality assurance mechanisms which completes the cvcle of: (a) development of monitoring systems; (b) actual monitoring itself;, and (c) coxrec- tine aabinn in arese af identified Aeficiencv. et ole Yee we er Wee roe me _ ~—— 2. All pro-arguments in Option 5. 3. The most appropriate existing institution which relates to a greater range of provider groups than just medical societies, as in PSROs. CON: 1. Not all RMPs are equipped to handle this responsibility. 2. Raises the question of whether providers should dominate regulation of their own activities. 3. Monitoring or regulatory power would jeop- ardize relationship that RMPs have developed with providers. | . -4, Would probably limit RMP to that activity because RMP would occupy an antagonist role with provider colleagues. 5. ° Most RMPs would probably resist assignment. OPTION 7. RMP should be eliminated completely. PRO: 1. In times of budget stringency substantial money could be saved. 2. Provider dcminated groups will not bring about major change in delivery systen. 3. See criticisms of Program in Section of Tab B. Page 7 - The Secretary CON: il. viders of Has taken 5 years to develop a workable link between Federal Government and pro- care; this would be lost. 2. Provides a flexible implementing mechanism at the community levei to work on propiem areas. ‘ 3. May not be politically viable. 4, See Program Strengths in Section I of narrative. OPTION 8. RMP should be eliminated as a Federal pro- gram; corresponding funds should be applied to health revenue sharing. ° PRO: 1. The Secretary has made a preliminary deci- sion to this effect. . 2. In addition to the PSROs under Option 7, the revenue sharing approach is probably more acceptable, politically, than outright elimination of the program. — CON: 11. Has taken 5 years to develop a workable link ~ between Federal Government and providers of care; this would be lost. Provices a flexible. implementing mechanism at the community level to work on problem areas. May not be politically viable. See Program Strengths in Section I of narra- tive. Oo QO . Page 8 ~ The Secretary RECOMMENDATION Primary Mission Secondary Mission Not Recommended RATIONALE CONCUR NONCONCUR - COMMENTS AND SUGGESTIONS € Page 9 - The Secretary B. © DECENTRALIZATION AND FUNDING ISSUR II. GIVEN H's RECOMMENDA'IONS AS ''TO RMP MLSSLUN, WHAT SHOULD BE THE EXTENT OF DECENTRALIZA- TION OF AUTHORITY TO THE LOCAL RMPs? DISCUSSION This issue is closely related to ISSUE I ~ MISSION. OPTION 1. Complete local authority. PRO: 1. Most nearly consistent with Administration philosophy of decentralization, © State res- ponsibility, and local initiative. 2. Most acceptable to the: RMPs and providers. | 3. Most compatible with relating to local needs, - objectives, and resources, and resultant local variations in approach and priorities as deter- mined ‘by CHP. CON: 1. May not address priorities set by identified RMP mission. 2. In face of funding. constraints and vossible cutbacks, it is unredsonable to expect rapi reorientation in line with new mission in absence of Federal direction. 3. Mav have little impact on national objectives. Page 10 - The Secretary OPTION 2. Partial, with local RMPs having latitude to pursue specific proposals within the broad pricrity areas as established by their redefined mission and local CHP plans. PRO: 1. Still reasonably consistent with Adminis- tration philosophy of decentralization. 2. Compatible with relating to local needs, variations, and CHP planning. 3. Helps assure that RMP activities will address broad national priorities. - CON: 1. Would not be as acceptable to RMPs and providers as Option 1. ° 2. Would not necessarily insure that all local RMPs would adequately address each of the several broad priority areas, ©-J-+, monitoring of quality of care. OPTION 3. Minimum decentralization -— discretion e re best methods of carrying out a strong Federal directive. PRO: 1. Would most nearly insure that local RMPs address broad priorities. 2. Important in achieving missions which warrant continuing support of RNP. oe Page ll ~ The Secretary CON: 1. Totally inconsistent with HEW decentraliza- tion philosophy of local initiative to meet local problems. 2. Unlikely that providers would willingly acu “Gepl suc stLony GiLeciionu. | 3. Runs counter to actual long-term trend of increasing decentralization to local RMPs. OPTION 4. Determine national objectives at the Federal ofan level; assign to CHP responsibility for deter- mining the degree to which national objectives are being met in the various States, and assign to RMP a major im- plementing responsibility for realizing national objec tives in accordance with CHP determination of relative ° eo needs. PRO: 1. To make a decentralized system accomplish na- tional objectives. There must be a clear arti- culation of these objectives; the CHP agency is the appro- priate mechanism for evaluating State and local circum- stances and problems in the light of national objectives. 2. The capabilities of RMP will be most effectively used through supporting the achievement of such objectives, and catalyzing the provider sector in that direction. CON: 1. The conccpt of health revenue sharing and de- centralization is to recognize State and local objectives which may be different from national objectives. O O Page 12 - The Secretary 2. A structure such as that proposed in this Option would so limit RMP that provider interest and support would be lost. RECOMMENDATION , : RATIONALE CONCUR NONCONCUR, e COMMENTS AND SUGGESTIONS ISSUE III. HOW SHOULD FUNDS BE APPORTIONED/DISTRIBUTED TO THE LOCAL RMPs? - - cee ‘ - oe VETLON be COME LELIVeE pLUyeUL vabin. PRO: 1. Improves review of individual proposals against priorities. 2. Allows better coordination of related activi- ties; helps minimize unnecessary duplication of effort. 3. Minimize local patronage and bias. CON: 1. Administratively cumbersome and costly HEW role. 2.° Unlikely to correlate funding with local. needs and problems as there would be a ten- dency for those RMPs and sponsoring institutions (e.g. medical schools) most proficient in grantsmanship and with the greater resources to obtain a larger share of the funds. 3. . Would not utilize the considerable local tech- nical review and decision-making capacity and structure that has been created by the RMPs over the past six years. OPTION 2. Comoetitivé vrocram basis. PRO: 1. Would provide better incentives for RMPs to address priorities. h level of competition 2. Would encourage al ely better activities. a and, thus, cunlit hid Ltatiy ZL 3. Would help overcome the criticisms (CONs) of Opticn l. Page 14 =~ The Secretary CON: 1. Would reduce flexibility once programs approved; RMPs would tend not to be as fully and rapidly responsive to possible changes in priorities. 2. Would tend to reward stronger RMPs and not weaker ones. ’ OPTION 3. Competitive basis with selected earmarks. PRO: 1. Earmarks would provide incentives needed to spur local RMPs to engage in activi- ties addressing high but less popular priorities (e.g., quality of care monitoring) that many of them otherwise might be reluctant to undertake. - 2. Closely coincides with present mode. 3. Offers advantages similar to Option 2. CON: 1. Earmarking, once resorted to, sets a prece- ~— dent for further earmarkings; at the same time it is difficult to get rid of previous earmarks even though they have outlined their usefulness. 2. ‘Disadvantages similar to Option 2. .t OPTION 4. Use a formula basis. e PRO: 1. Consistent with HEW position on local initiative. 2. Provides local PMPs with significant flexibility. 3. ‘Hore nearly results in an equitable distribution of funds to all RMPs. Page 15 ~- ‘ne secretary CON: 1. Little or no incentive to use funds to address national priorities. 2. Difficult to develop a formula adequately takina into account potential resources and needs in various specific priority areas that would be equitable to all States. OPTION 5. On a formula basis with selected earmarks. PRO: 1. Would allocate specified sums for special priorities. 2. Provides fiscal equity to all areas. 3. Would require RMPs to develop proposals within each earmarked area, even if that. resulted in funding some weaker projects in one given priority area at the expense of additional stronger projects in another. ” . CON: lL. Earmarking, once resorted to, sets a prece~ dent for further: earmarks; at the same time it is Gifficult to get rid of earlier earmarks that have outlined their usefulness. OPTION 6. Use a combination formula-competitive basis. PRO: 1. Provides a financial base for long-term commitment to professional staff. 2. Provides for competition. CON: 1. Mav have programs sending stronger projects | For corvetition and funding weaker nonpriority toe 1 + we Foner projects out of tne LOrmusa. Page 16 - The RECOMMENDATIO RATIONALE CONCUR secretary | N NONCONCUR COMMENTS AND f SUGGESTIONS Page 1? - The Secretary - Cc. «£ ORGANTZATION OF LOCAL RMP UNIT ISSUE IV. FROM WHAT CATEGORIES OF PEOPLE SHOULD THE LAW REQUIRE REPRESENTATION ON THE BOARD? OPTION 1. Providers, consumers, elected officials, low income consumers, third parties, and CHP. PRO: 1. Encourages well rounded board composition. CON: 1. May be too restrictive to be practical in all the areas. . ws 2. Providers may feel under-represented. LES OPTION 2. Providers, consumers, elected officials, low income consumers. (Eliminates from Option 1 third party and CHP representation.) PRO: 1. Third party and consumer representation are redundant. ion on board is not necessary lew and comment on, or review COM: 1. TRird parties ana CHP vrovide ditferent ters- pectives on prcebliem areas and priorities that need to be addressed by Rip. O OPTION 4 Page 18 - The Secretary OPTION 3. Providers, consumers, electe ed officials, and CHP (This Option eliminates desig- nation of low incom consumers from Option 2.) PRO: 1. —— Provides more flexibility for organizing boards. CON: 1. Low income consumers often experience dif- ferent types of problems than do other con- Sumers and therefore might provide a good balance to the board. Providers, consumers, nd low income con- sumers. (This Option deletes specific men- tion of elected officials from Option 2.) PRO: 1. More flexible than Option 2; and allows for elected officials under: "consumer": designa-. tion, without specifically mentioni ing them. Con: il. Elected offi source of (¢é Cials often are an important Suppo ort for the program as well as sensitive to local issues and pressures. OPTION 5. Providers and public revresentatives. PRO: 1. Most. flexible. 2. Permits each State to put together most effective grouso for their own particular areca. CON: 1. esentation of Page 19 ~ The Secretary RECOMMENDATION ray RATIONA tH td CONCUR NONCONCUR COMMENTS AND SUGGESTIONS ¢ Page 20 - The Secretary ISSUE V. SHOULD THE POLICY BOARD HAVE A MINIMUM REQUIREMENT CONSUMER PARTICIPATION? OPTION 1. Yes (20 percent) PRO: 1. Shows a clear commitment by to consumer representation. the Department CON: 1. Reduces flexibility; may not be necessary. 2. May be useless tokenism. OPTION 2. Yes (33 1/3 percent) PRO: 1. Shows a stronger commitment to meaning-~- ful consumer participation and inveivenent in decision making. ” CON: 1. Same as CON 1, Option 1. - OPTION 3.: Yes (51 percent) -¢ PRO: 1. Shows strong commitment to consumer repre- sentation. CON: 1. Same as CON 1, Option i. 2. May harm relationshixos undo what RMP has de rele five years. hp ea 6) =. @ ctr oviders and over the past O Page 21 - OPTION 4. PRO: Id. ?. CON: id. The Secretary No requirement. Most flexibility Dn nat have to address this issue at ' this time. Discredits HEW commitment to consumer participation. RECOMMENDATION RATIONALE e CONCUR NONCONCUR O Page 22 - The Secretary ISSUE VI. SHOULD THE LAW REQUIRE RMP TO HOLD PUBLIC HEARINGS ON PROPOSED RMP ACTIVITIES? OPTION 1. Require RMP to hold public hearings in ad~ vance of approving proposed projects. PRO: 1. This would provide an opportunity for effec- tive public involvement. CON: 1. This would unnecessarily duplicate existing reviews. 2. CHP should provide the primary form for public comment on proposed governmentally financed activities in the health care field. 3. Public hearings directed to the review of individual projects would.be unduly cumbersome. OPTION 2. Require RMP to hold public hearings on a general outline of proposed programs but not with respect to awards for individual projects. PRO: 2. Provides appropriate opportunity for public input in a,simpler and more expeditious manner. ‘CON: Jie: Hearings of this sort woute be too abstract ae sto. be effective. 2. See CONs under Option 1. COMMENTS AND SUGGESTIONS fo Page 23 - The Secretary OPTION 3. Authorize but do not require public hear- ings. —— PRO: 1. This would permit RMPs to tailor the use of the public hearing process appropriately to the nature of the issues that are under consideration. CON: 1. If left optional, the public hearing process would probably rarely be utilized. RECOMMENDATION RATIONALE CONCUR ct NONCONCUR a tes . ,e Page 24 ~ The Secretary _ ISSUE VII. SHOULD RMP LEGISLATION REQUIRE CHP APPROVAL e AS A PRECONDITION FOR FUNDING RMP PROPOSALS? PRO: 1. Strengthen CHP. 2. Establishes planning as a precondition for, and controller of implementation. 3. Reasonably assures that Federal money will not be used in a manner incompatible with other relevant programs. CON: 1. Heavily restricts the provider role; may be unacceptable to providers. 2. CHPs are not qualified, technically, to con- trol provider-sponsored projects not to res- pond in a timely fashion; therefore,” this would not be a realistic requirement. OPTION 2. Provide for review and comment, but not for an approval (i.e., veto) authority. PRO: 1. Less restrictive and, hence, more acceptable. | 2. CHP should, at a minimum, have a review and comment role. 7 CON: 2. , CHP. should. have a stronger, role. than mexe . review and comment. 2. Yhere is reslly no very comp Lopes ., 4 a . Por Cit. te occ imvocivea at at O “> RECOMMENDATION srt ee oe . £4 ' - to, r for * ee ’ RATIONALE CONCUR NONCONCUR COMMENTS AND SUGGESTIONS v eee ye | ata? f Vout ee AAS hy a { a f SURO bu bebe as Cage tO