888
DATA FOR LOCAL HEALTH-PLANNING DECISIONS* MARVIN D. ROTH Director of Health Planning City of New York Department of City Planning New York, N.Y.
H
EALTH planning, like computer science, is now entering its third generation. The areawide agencies for the planning of health facilities, developed in the early 1960s under the federal Hill-Burton program, might be considered the first generation. The main achievement of these agencies was the advancement of the concept of health planning on an areawide basis. This goal having been accomplished, they were followed by the comprehensive health-planning agencies (CHPA) created in 1966 under Public Law 89-749. The second generation prompted the concept of a broad base for planning, to be provided through input from providers and consumers of health care. By mandating consumer majorities on the board and the committees of health agencies, this legislation stressed participation by consumers. With the health-systems agencies (HSA) which are being developed under Public Law 93-641 we are now entering the third generation of health planning. In computer science the third generation was brought about by improved technology. In health planning we have the third generation but to a large extent we do not have the advanced technology. It is essential that the technological advances be made to justify a third generation; planning must be advanced from an art form to a scientifically based modality. A recognition of this need to place planning on a firmer base is embodied in the federal legislation which requires the development of a health-systems plan and an annual implementing plan. This requires an understanding of the role of data and of the types of data needed. To carry the analogy with computers one step further, note that data and other informational inputs are a critical element of a scientific perspective. The concept that a data base is needed in planning for health is not new. *Presented as part of a Seminar on Data Needs for Health Planning and National Health Insurance held by the Task Force on the Impact of National Health Insurance of the New York Metropolitan Regional Medical Program at the New York Academy of Medicine May 13, 1976.
Bull. N.Y. Acad. Med.
DATA FOR LOCAL HEALTH-PLANNING DECISIONS
889
The first and second generation health-planning agencies devoted much time and effort to the gathering of data. In fact, the main activity of some of these earlier agencies was the compilation and publication of data, much of which was of little use. In the 1960s, when many of the new comprehensive health-planning agencies did not know what to do or were not sure what health planning was all about, to some extent they gathered data merely in order to justify their existence. As a result, a large body of data was gathered. However, when important decisions had to be made there was a minimal factual base that could be used in the process of making decisions; the procedure for collection of data had not been designed to meet the needs of the decision-makers. The collection and publication of data is not an end in itself; it is merely a means to an end. The desired end can be attained only if one keeps in proper perspective the role of data in planning. The data programs of the early health-planning agencies encountered several problems. Facts were often gathered without appreciation of their potential use. For example, collection instruments such as questionnaires and schedules were often developed before issues had been clarified. As a result, data were assembled which were not relevant to the problem. Further, data were gathered but in many instances were not analyzed. Collecting data is easier than analyzing them. There also was confusion concerning who should analyze data the lay boards and committees of the CHP agencies or the technical staff. The respective roles of committees and boards and of professional and technical staff tended to be confused. There was, and still is, confusion concerning the role of data in the process of decision-making. Some of the committees and task forces of the CHPA were unwilling to make decisions and were awaiting the allimportant computer print-out that was expected to provide the answers. Too many persons have been mesmerized by the magic of computers and computer print-outs and have looked reverently to these false gods. Data by themselves do not make decisions or provide answers. Many other factors influence the decision-making process and must be considered. Many of these factors cannot be quantified and, in some instances, these intangibles should be of greater importance in the final decision than the quantitative data. Data are a tool honed by the technician for use by the decision-maker in focusing on the principal issues and in identifying alternate solutions. The functions of the technician and of the decision-maker as it relates to Vol. 53, No. 10, December 1977
890
890
M. D. ROTH M. D.RT
data have to be differentiated. The technician assembles, analyzes, and works with data. The technician suggests goals, objectives, and alternative solutions to problems. However, the decisions are made by the committees and boards of the agency. These groups combine the data and other inputs of the technician with other considerations, many of which do not lend themselves to quantification, and develop the final recommendations. These recommendations and decisions must be integrated into an overall system. Health planning, like health care, has been excessively fragmentary. In the past there has been too much emphasis on particular proposals, e.g., should XYZ Hospital add another 100 beds? Generic issues should be confronted, such as the need for hospital beds in the Bronx and the relation between this need and the need for other modalities of care. It is to be hoped that the health-systems plan mandated by the new federal legislation will remedy this situation. This also requires that the appropriate data be available to assist the decision-makers. Several problems are related to the availability of data. We have to make technical advances in this area. The second generation health-planning agencies have identified many of the data elements that are necessary. However, now we must sharpen our concepts of what the data indicate. Also, there are several data areas which will need immediate attention. In considering concepts we have not defined our terminology clearly. For example, in recent years much study and effort have been devoted to developing an index of health scarcity. While much has been written, no satisfactory index has been developed. One reason is that the concept of health scarcity is vague. Does it mean an area which lacks resources? In this case, it will be necessary to develop additional resources in the area. Does it mean an area in which levels of health, as best we can measure them, are poor? If this is the case, a different approach would be required in areas which do not have sufficient resources as contrasted with areas that have sufficient resources. Does it mean an area in which utilization of health resources is low? Here again, this relates to the health levels of the population and to the availability of resources. Unless we know more precisely with what we are dealing, we are continually mixing apples, oranges, and onions-and ending up with a tasteless salad. There is also a tendency for many who work with data to become excessively involved in the level of data that are required and significant. Some who work with data tend to deal not only with micro data but also with micro-micro data. The data dealt with in the planning field are in Bull. N.Y. Acad. Med.
DATA FOR LOCAL HEALTH-PLANNING DECISIONS
891
many instances imperfect. Therefore, often they have meaning only on the macro level, and to deal with them on the micro-micro level is sometimes self-indulgent. This is like the old adage of "losing sight of the forest for the trees." One wonders whether some data technicians might be losing sight of the trees for the leaves. Another aspect of the level of data is geographic. The facts about local areas often are not available for many of the characteristics that planners need. This is true whether we define a local area as New York City, the borough of Brooklyn, or the community of Sunset Park-Bay Ridge. Since planning is space-related, it is important that data be site-specific. Many problems relating to data for local areas remain to be overcome. For example, there is no simple method for determining health-manpower resources by local area; there is a paucity of information on where and how the residents of a particular area receive ambulatory care; and there is no information on health-care expenditures by and for residents of a community. Better financial information is needed. Most fiscal data systems do not lend themselves to providing data for planning. Much of the information needed by the planner could be generated as a by-product of routine fiscal operations. In addition, many planners do not give sufficient consideration to the fiscal implications of various proposals. For example, very often the costs of various alternatives have not been ascertained. Little consideration is given to the marginal utility of additional expenditures. There is the dual problem of having the necessary data available and having the planner appreciate its usefulness. Fiscal data systems should attempt to meet some of the needs of planners. This could be accomplished by providing for retrievability of the various data elements. Health-manpower resources constitute another topic for which we require localized data. Many experts question whether some of New York City's health problems are more closely related to distribution rather than to the supply of health manpower. While we know something about the supply, we know little about its spatial distribution. Obviously, much information is required for health planning. The local health-systems agency should not and cannot be expected to have all this information in its files. It is essential that the data flow in two directions-both from the health-systems agency to local and state governmental authorities, third-party and other insurance carriers, professional standard review organizations, and health providers, and from these groups to the health-systems agency. Vol. 53, No. 10, December 1977
892
892
M. D. ROTH
M. D.
ROTH~~~~~~~~~~~~~~~~~~~~~~~~~
As a technical device, data are neutral; their value is a function of their use. Properly gathered and used, they have many positive effects. Improperly used, they can waste time, money, and paper, and fail the needs of the decision-makers by not shedding light on the optimal solution.
Bull. N.Y. Acad. Med.
DATA FOR LOCAL HEALTH-PLANNING DECISIONS* MARVIN D. ROTH Director of Health Planning City of New York Department of City Planning New York, N.Y.
H
EALTH planning, like computer science, is now entering its third generation. The areawide agencies for the planning of health facilities, developed in the early 1960s under the federal Hill-Burton program, might be considered the first generation. The main achievement of these agencies was the advancement of the concept of health planning on an areawide basis. This goal having been accomplished, they were followed by the comprehensive health-planning agencies (CHPA) created in 1966 under Public Law 89-749. The second generation prompted the concept of a broad base for planning, to be provided through input from providers and consumers of health care. By mandating consumer majorities on the board and the committees of health agencies, this legislation stressed participation by consumers. With the health-systems agencies (HSA) which are being developed under Public Law 93-641 we are now entering the third generation of health planning. In computer science the third generation was brought about by improved technology. In health planning we have the third generation but to a large extent we do not have the advanced technology. It is essential that the technological advances be made to justify a third generation; planning must be advanced from an art form to a scientifically based modality. A recognition of this need to place planning on a firmer base is embodied in the federal legislation which requires the development of a health-systems plan and an annual implementing plan. This requires an understanding of the role of data and of the types of data needed. To carry the analogy with computers one step further, note that data and other informational inputs are a critical element of a scientific perspective. The concept that a data base is needed in planning for health is not new. *Presented as part of a Seminar on Data Needs for Health Planning and National Health Insurance held by the Task Force on the Impact of National Health Insurance of the New York Metropolitan Regional Medical Program at the New York Academy of Medicine May 13, 1976.
Bull. N.Y. Acad. Med.
DATA FOR LOCAL HEALTH-PLANNING DECISIONS
889
The first and second generation health-planning agencies devoted much time and effort to the gathering of data. In fact, the main activity of some of these earlier agencies was the compilation and publication of data, much of which was of little use. In the 1960s, when many of the new comprehensive health-planning agencies did not know what to do or were not sure what health planning was all about, to some extent they gathered data merely in order to justify their existence. As a result, a large body of data was gathered. However, when important decisions had to be made there was a minimal factual base that could be used in the process of making decisions; the procedure for collection of data had not been designed to meet the needs of the decision-makers. The collection and publication of data is not an end in itself; it is merely a means to an end. The desired end can be attained only if one keeps in proper perspective the role of data in planning. The data programs of the early health-planning agencies encountered several problems. Facts were often gathered without appreciation of their potential use. For example, collection instruments such as questionnaires and schedules were often developed before issues had been clarified. As a result, data were assembled which were not relevant to the problem. Further, data were gathered but in many instances were not analyzed. Collecting data is easier than analyzing them. There also was confusion concerning who should analyze data the lay boards and committees of the CHP agencies or the technical staff. The respective roles of committees and boards and of professional and technical staff tended to be confused. There was, and still is, confusion concerning the role of data in the process of decision-making. Some of the committees and task forces of the CHPA were unwilling to make decisions and were awaiting the allimportant computer print-out that was expected to provide the answers. Too many persons have been mesmerized by the magic of computers and computer print-outs and have looked reverently to these false gods. Data by themselves do not make decisions or provide answers. Many other factors influence the decision-making process and must be considered. Many of these factors cannot be quantified and, in some instances, these intangibles should be of greater importance in the final decision than the quantitative data. Data are a tool honed by the technician for use by the decision-maker in focusing on the principal issues and in identifying alternate solutions. The functions of the technician and of the decision-maker as it relates to Vol. 53, No. 10, December 1977
890
890
M. D. ROTH M. D.RT
data have to be differentiated. The technician assembles, analyzes, and works with data. The technician suggests goals, objectives, and alternative solutions to problems. However, the decisions are made by the committees and boards of the agency. These groups combine the data and other inputs of the technician with other considerations, many of which do not lend themselves to quantification, and develop the final recommendations. These recommendations and decisions must be integrated into an overall system. Health planning, like health care, has been excessively fragmentary. In the past there has been too much emphasis on particular proposals, e.g., should XYZ Hospital add another 100 beds? Generic issues should be confronted, such as the need for hospital beds in the Bronx and the relation between this need and the need for other modalities of care. It is to be hoped that the health-systems plan mandated by the new federal legislation will remedy this situation. This also requires that the appropriate data be available to assist the decision-makers. Several problems are related to the availability of data. We have to make technical advances in this area. The second generation health-planning agencies have identified many of the data elements that are necessary. However, now we must sharpen our concepts of what the data indicate. Also, there are several data areas which will need immediate attention. In considering concepts we have not defined our terminology clearly. For example, in recent years much study and effort have been devoted to developing an index of health scarcity. While much has been written, no satisfactory index has been developed. One reason is that the concept of health scarcity is vague. Does it mean an area which lacks resources? In this case, it will be necessary to develop additional resources in the area. Does it mean an area in which levels of health, as best we can measure them, are poor? If this is the case, a different approach would be required in areas which do not have sufficient resources as contrasted with areas that have sufficient resources. Does it mean an area in which utilization of health resources is low? Here again, this relates to the health levels of the population and to the availability of resources. Unless we know more precisely with what we are dealing, we are continually mixing apples, oranges, and onions-and ending up with a tasteless salad. There is also a tendency for many who work with data to become excessively involved in the level of data that are required and significant. Some who work with data tend to deal not only with micro data but also with micro-micro data. The data dealt with in the planning field are in Bull. N.Y. Acad. Med.
DATA FOR LOCAL HEALTH-PLANNING DECISIONS
891
many instances imperfect. Therefore, often they have meaning only on the macro level, and to deal with them on the micro-micro level is sometimes self-indulgent. This is like the old adage of "losing sight of the forest for the trees." One wonders whether some data technicians might be losing sight of the trees for the leaves. Another aspect of the level of data is geographic. The facts about local areas often are not available for many of the characteristics that planners need. This is true whether we define a local area as New York City, the borough of Brooklyn, or the community of Sunset Park-Bay Ridge. Since planning is space-related, it is important that data be site-specific. Many problems relating to data for local areas remain to be overcome. For example, there is no simple method for determining health-manpower resources by local area; there is a paucity of information on where and how the residents of a particular area receive ambulatory care; and there is no information on health-care expenditures by and for residents of a community. Better financial information is needed. Most fiscal data systems do not lend themselves to providing data for planning. Much of the information needed by the planner could be generated as a by-product of routine fiscal operations. In addition, many planners do not give sufficient consideration to the fiscal implications of various proposals. For example, very often the costs of various alternatives have not been ascertained. Little consideration is given to the marginal utility of additional expenditures. There is the dual problem of having the necessary data available and having the planner appreciate its usefulness. Fiscal data systems should attempt to meet some of the needs of planners. This could be accomplished by providing for retrievability of the various data elements. Health-manpower resources constitute another topic for which we require localized data. Many experts question whether some of New York City's health problems are more closely related to distribution rather than to the supply of health manpower. While we know something about the supply, we know little about its spatial distribution. Obviously, much information is required for health planning. The local health-systems agency should not and cannot be expected to have all this information in its files. It is essential that the data flow in two directions-both from the health-systems agency to local and state governmental authorities, third-party and other insurance carriers, professional standard review organizations, and health providers, and from these groups to the health-systems agency. Vol. 53, No. 10, December 1977
892
892
M. D. ROTH
M. D.
ROTH~~~~~~~~~~~~~~~~~~~~~~~~~
As a technical device, data are neutral; their value is a function of their use. Properly gathered and used, they have many positive effects. Improperly used, they can waste time, money, and paper, and fail the needs of the decision-makers by not shedding light on the optimal solution.
Bull. N.Y. Acad. Med.
