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Health systems agencies and local physicians.

IT IS SAFE to assume that relatively few physicians and less of the public are more than vaguely aware of the National Health Planning and Resources Development Act of 1974 (PL 93-641) or of the proposed Health Planning and Resources Development Amendments of 1978 (HR 10460) now being considered by the Congress. Everyday patient care and professional practice will be profoundly influenced by the way this law is implemented and its reach no doubt extended. If the federal strategy (to use a federal term) succeeds, the local Health Systems Agencies (HSA'S) will have a great deal to say about local planning for health care and the expenditure of federal funds for health in their area. PL 93-641 grew out of three former federal programs and combined and strengthened them. These were Comprehensive Health Planning, Regional Medical Programs and the Hill-Burton Act. PL 93-641 divides all of the United States into health service areas (also HSA's). Within each area it sets up a Health Systems Agency (HSA). The local HSA is a regional or area agency which may be a private nonprofit corporation, a unit of local government, or part of a public multipurpose planning agency. Each HSA has a fulltime staff, paid by the federal government, who collect and analyze data and make recommendations to the HSA governing body. An HSA executive committee or governing body is made up of 20 to 30 members. Consumers must be in the majority. In addition several categories of '"providers" must be represented in the nonconsumer portion. It works out that the slots for practicing physicians are quite limited, perhaps one or two on each HSA governing body. The same mix applies to all the HSA councils and committees as well. The local HSA'S are now in various stages of development throughout the nation. At the same time something of a four-way power struggle seems to be going on within government. The Congress perceives the power to lie in the consumer-dominated local HSA'S, with federal guidelines to help them. The federal bureaucracy in the Department of Health, Education, and Welfare, responsible for developing the regulations, sees the federal guidelines more as federal mandates to be followed by the local HSA'S. The state governments under the law have a role in coordinating statewide HSA activities and steering HSA'S toward statewide goals, and they are presently jockeying with the federal government for the power to do this. And lastly, many local governmental authorities are seeking as much dominance and control of local HSA's as possible. So once again we seem to be embarked upon a massive, complicated and costly federal health program which is based upon a theoretical hypothesis which has never been tested and may or may not ever work. The potential for havoc is great, but there is also potential for good, for a more rational approach to health care at the local level, with some coordination at the state level and some help and guidance from the national level. The omission, almost to the point of exclusion, of a significant presence of practicing physicians at each level of planning and decision making under this law seems to be a flaw which may prove serious and could even be fatal. There are great expectations of the conventional wisdom of the consumer and of the knowledge and expertise of other "providers" of health care. Yet it is the physician who in many ways is the most knowledgeable person of all about much of what is involved, and physicians are in a position to give expert counsel and advice which may or may not be sought, or listened to. It is worth emphasizing that the HSA'S may actually be ushering in a new period of participatory democracy in health care. This may prove to be the wave of the future. At present it is an experi-