I DEPARTNIENT OF HEALTH, EDUCATION, AND WELFARE MEMORANDUM PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION TO Regional Health Administrators 13UREAU OF HEALTH RESOURCES DEVELOP?,fENl- DHEW, Region I-X DATE: October 24, 1974 Through: Director, ORO FROM Acting Associate Director for Health Resources Planning SU13JECT: Proposed HRP Area Designation Process Enclosed for your review and comment, is a draft proposal as to (1) the tasks or steps to be performed with respect to HRP area designation, (2) who would have principal responsibility for the initiation and performance of each of those, and (3) the timetable for their achievement. To allow sufficient time for the careful review and consideration that I believe this warrants, you have until November 15 to submit your comments. To be most helpful, your comments should be as specific as possible, specific not only as to suggested changes themselves but the reasons therefor. There are several issues and problem areas, highlighted below, that I would call your attention to and invite your comments on praticularly. Before highlighting those, however,-there are several assumptions under- lying this draft proposed process that best be made explicit. 1. It is based on H.R. 16204 and the area designation requirements and timetable set forth in that bill. S.2994 as reported out by the Senate Committee differs significantly; for example, it would permit nearly a year for the area designation process to be completed, does not mandate minimum or maximum population limits, and requires regulations. 2. The House bill requires a Notice, but not regulations, to be published within 30 days of legislative enactment. That Notice, we have assumed, essentially will reflect only those area designa- tion requirements, both substantive (e.g, population) and process (p.g,., consultation with local officials), set forth in the legis- lation itself. Thus, there will also be a need for separate clarifying and elaborating guidelines, but not regulations per se. 3. In view of the fact that neither the House nor Senate has passed a bill and that the Congress will not reconvene until November 18, there is little likelihood that final legislation enactment will occur much before the end of December. There are as I have noted, a number of issues or problems raised by this draft AD proposal. Among them: 1. It proposes that the Secretary, who must approve the area designations proposed by governors, deleaate to ASH that official authority. Should it be further delegated by ASH; and if so, to whom (e..g., Regional Health Administrators 2 Administrator HRA.)? The draft assumes that regional offices will have the principal responsibility for reviewing proposed designations, that their recommendations would be tantamount to approval in the great majority of instances, and thus, they in effect and to that extent would exercise the actual as opposed to official approval authority in any case. 2. Central office or headquarters staff would have a minimal role in reviewing proposed designations. The scope of the central office review would be limited to "exceptions," namely, (a) all waiver requests, (b) proposed inter-regional designations, and (c) any regional office recommended non-approvals of proposed areas that ostensibly meet the prescribed, objective require- ments with respect to population, SMSAS, and the like. Moreover, that review would be more in the nature of staff work for the proposed ad hoc Review Panel rather than central office concurrence or non-concurrence. 3. A Review Panel, of two central office and three regional office representatives is proposed. It would review certain "exceptions," and its recommendations as to approval (or non-approval) in effect would be binding in instances where they differed from those of the regional office in question. 4. This draft proposal defines "exceptions" per item 3 above. (Also see III.3.A of the enclosed draft.) Is that definition satisfac- tory; if not, what specifically should be added or deleted? 5. Govenors are required to submit their area designation plans within 90 days after the initial notice in the Federal Register; and the Secretary in turn must publish approved designations in the Federal Register within 150 days of that notice. Within those 60 days review must take place. Little time will remain after review to (a) negotiate substantive revisions required as a result of waiver requests denied or other non-approval actions or (b) for the Secretary to designate acceptable areas in lieu thereof. Should a minimum grace period of 30 or 60 days be permitted? With or without such a grace period, who at the Federal level should be responsible for designating areas in these States where this either had not been done or after negotiations have failed; and how should this be done? Among the possible alternatives are to have this done by the RHA and regional office in question, or in conjunction with the central office. Regional Health Administrators 3 In closing, I would remind you that this is a draft proposal developed by the Area Designation Work Group with the assistance and advice of several regional office staff. It no doubt can be improved by your constructive comments and suggestions. Rubel Enclosure 400 H w (U la 0 cj 4i Cd 0 E-1 PCs bo 0 r3r4 0 0) Cl) 0 E-4 Cd z 4 0) 4i 0 u I m Cd 930 . c4i 0 4i bo 4i a) to 4.4 -H 10 0) 0) Ca go (Li z 0r. law 44 ra 0t7. 4i0 4) co 4) 4i 4) 0 a 4) m i, En Ci 54 rJ)0 54 4i co 4i 0 04i w-H Cd 0Ea co 0 14 4) 4J 4J -H 14 4i P. la Q) CO 14 0) Ca a) cn -H f5 4i (L)> bo 4i 04i 4-i bo 0) -4 4i r4 0u m -cd 14 0) $4 :j -H Cd IH co Wcd 4i 0 rn ta P4 -H rn 14 Dt 4i 4i 0) -H En 44 4i m :1 r. u OD V. @ 14 0 mm -4 ol 0 4)0 0) . 0 41 co a)u 43 4i U14 $4 $4 co -H Cd 0 4i 4j 4i rA :3 co 0) Q) CO 14 -r4 co u r. -H .0 14 4i u r, r4 Cd (L) 10 4) r40 C/3 0 u -44 0'O 44 B 00 ww wA >0 V4 co -H ri 4i 14 r.> :3 -4 0 cd0 w 44 -H la C- 0 Cd r. 0 0 4i 0; 0) mr-i 0 P4 4-4 04i u 4i i% -H 0. 00 0 4i 0 44 4) 4i vi 4i cu 0 co Cd 0 140 4-i co w-H Cd 04 IQ 4i m 4) 0.0 0 > 4i oi 0 (LI ct) Z:3 14 14 0la En 14 0) cow r4 10 co -H ci 4i cu -H -H r. z 93 (I)- H :1 @ =:3 bo 14 0 0 0 to a, bo 14 %a UV - 0 4i -H 4i Cd 0) la 93 0) Cd 4)0 boo 4i 44 -H C-w r. -H 4i rn $4 rn co 44 0 :t m Ed 4i (a r4 ri) 0 44 14 -H .M (L) 4) 0 co ta 14 0 00u r-I -i a) - u 4i r. $-4 cn 44 -H 014 4i .0u0) m > 0 cd 0 rj Cd -H Cd IH 0) (L) 00u Aw $4 10 r. -H -A :3 E-4 4i r. m 4ic 0. IH0 cow 1% r.0$4 ra 10 $4 0 0 a) W4.J $4 -H (Li 4)10) la 93 0 z 4i 0)0 v-0 (i r. rb r.0 4i 4) 0 0 bo to 0 44 2? Cd En Cj 0) 4i CO :J 44 44 Ca IH to 0) $4 rn bo0 .0 .44 10 4) 4i 4i r-I -8 U) r. co 0 9) (L) 4i LIO co 0 co -H 14 ,,, 14 14 4) -H -H 4i 93 . . E m 144.0 Ca = - @9 cd -H cn co0Ai 4i Cd C) d,M CA 0 0 -H 0) ro 4-4 U co r-i 4i " 10 co co a-H 0 -H Cd 44 > -H 00 (i) -H U (i) a) co r-i 4i CO 44 co 4i IH 0 :2 W0)W Cd W0 00 140-H $4 @ 0)0 44 r-i co 4i H PCI -4 -0 0)W 0) 040 'PI V4 E c: 0 0 C4 14 P4 .4 4 C4 C,4 ba 4i Cd co 0 4i r4 r-4 0 C'4 4-i tn cn C.) E-4 CQ co Ca 1-4 4i 4i z CA U3 z 60 0 . 1-4 u E-4 04 0 ,< :x0 z C) 44 00 1-4 0 0 41. co -14 -H 14 4). 4i $4 'O (A 14 CO0 Cd 4i @ -H :3 :3 -H 93 co 4i Cd 4> u4i 0 4J 4i -H U3 0r4 0) 4i co m 0 4) Ln uu co V4x 00 0 4i 4i q) 14 -H 4) 0) co 4) Cd 4i 4i to 93 la Q 0.1 ci U3 4) Cd 0 0 bo r-i 4J $4 U $4 Cd Z00 -H 4i 4i :3 . r-i 4) w :3 ri) co 14 10 com En cr Iq 04) 0 Cd 0 44 t) 0 00 14 4i (Li 140 44W co bo co 4i cn 04 4i P. 0co r4 -H co 44 Si 44 4J 14 14 41 4) 0 Ca0a 09 0 . . bo 4i 79 41 4i rA Cd 414 4i1 cn 0) 0 ci 0. 14 Od 0 4i 14 W.0 0) 0 m 2 0 04 -H -H z -H %a 0 14 Cd :3 78 0 4i 0co 0 0 (d GO -0 4i co 4i 14 co0 E-4 4J co rq $4 tko 44 CO 14 cn to (d 0. co co 4)m :9 14 4J f.) u0 4i 4i 0 to H ra 0ot 4i 4i Cd Cd w0 co 0 rix E-4 CX 14 m 10 co od- (L' o> 13 w 4) 00 ol :1 .54 Cd 4) co0 -H w to &au 0 4i 4i ti 1% a 10 w . 44 0 oi 4i 4i 4) 4; -H 4i co 78 u 41 14 rA rd $4 $4 Cd 014 u co0-H to 0 93 a) IH 4i 0 $4 $4 4i 0 C) 4i co -H C,4 0.0 @.0 -H 0 -H Is 9 4)0 w 4i 4i $4 $4 CO :3 CO 14 k;4 0 ri) 4) co $4 44 04 C) 14 A4 Cd PW Cd 04 04 Cd -H $4 oi Cd A4 . -H u r4 C4 4 c4 C4 > U3 r-f 1-4 4i %.O CY) tko 4i co r. tn PW co co cd 14 VW pq to $4 t4 4i 0 04i C.) La 4i 4i C3 co 4) IC co 4i 4i 0 03 Cd la 14 0) 4i :3 bo -d 0 4) 4i 4i 4i 0 tn tn 4i rA E-4 >4 P4 .4 u co 4) 1 L) 0 IL) 0 OD $4 4i bo m 0 93 4i cri 0) dCd 1-4 6 0) El 4i 44 CO Cd 0 -0 0 44 4i 4i z 93 14 0 0 -H 0) M $4 4-1 4i :I 0 0 w 1-4 -H 0 H 4i cd > 0 0 14 u 0 co 4j -H U -H I I z 93 to Cd 4i co 00 u4) ta 0 0 4) - C -H co co ta 4i 1$4. 4i 4i -H mu w 14 Cd 4J (A. 4i 4i m rA 10 'd ra m 114 "7 gi - - -9: a) 4) 0 4i co '40) . . m U. 4j 0 > 4) -H 0 4i co 4) 0 0 -H go 10 0 Is 41 m la -H r. r4 ig 4i 4i 4i 0 co m m .0 co " 44 9 .0. M= O. co 4i q) 4i co PN m 10 0) 0 to $4 4i @ Q) U 44 94 14 0. 10 la w 14 M co (L) Cd $4 Cd 041 Ai m 04. 0 0 r . . ci 0) m 4; r4 ..H 14 4) V. 14 cd 4i t) 0 m 14 a) c co $4 -H .0 9 0. co 4) 44 - %a 'Q) w 4) 0 4i 0 0 9 4i 0) 0 - 8 = I -H 0 4i :3 tko u $4 4i Cd 14 0 Ai m 44 V. 0) P* 0 bo 4i Cd -H 0) . $4. >% Cd 14 co 0 4) 0 44 H 4j 4) r-i C 41 .0 0 14 "4 0 0 4io co P4 Cd 14 U &a .0 -H 4i 4i . -H 0 4i 0 4i U Ca .0 Cd :i 0 4i 44 U 4i cn 0) 44 4) 4) rA .0 4i. C) 0 to 4i $4 r" 0 4i 4j 4i -H Cd -H .4) U. 44 4) 0 z ci Cd C: m .14 4i co 0 4i 0 0 -H 0) 4j 4i m co .4i 4i co AJ 4) 4i L) $4 $4 to to u 4i 0 -H 0 9: ci to u m Cd 0) w m -a --0 G) 14 44 -H (LI > -H r4 54 U- O' CO 4J 4j- 14i H rA 104 0 4) co 04 00 $4 M 44 0) C) 0 0: Z 4) 14 . t) E4 4i Cd 4i V4 0 4) z 0. m 0 -A 4) 14 41 co - 0). -H 14 0 14 Cd P4 o .0 - 4i -W 0) 0) to 0:14 ta 0).44 0 cn 4) -W 4i @> 4i rq 4) co Oa 4i -H > 0) 03 co to co r. Cd lj 2 w cd c 0 co . A'o >% " -H Cd r. > co -H M. $4 4j .449 4i to 0 04 "4 C 0 -H Cd 00 V4 0 14 cd -H '-H. cd -Li 4 0. 64 4i 4i 4.3.U. bo co 04 0; 44 .0 0) 0. r. rn > 0) 0.@ Q) $4 0) P. 0) M .0 0 :3 44 44 :3. 14 -4 cda co -H CO 4i od C, -,I .4 z E r4 Pd to 04 $4 cn 0 0 od 04 4) C4 C,4 cn C,4 cn -0. PZ 46