I THF4 H@URTON PR A CRITICAL REVIFW 1947-1952 John W. Cronin, M. D. Div-sion of 'iospital Facil4.4"lies Public Health Service P.W@-S ty Agen@ 0,S, 08Paitment of Health, EducaNon, and Welfam Five years have elapsed since the National Hospital Survey and Constri-ic- tion Program@ popularly known as the Hill-Burton Programp was authorized by Public Law 725, 79th Congress on August 16, 194(o. The first appropriation was received in 1947. It is, therefore., timely to review as objectively as possible the affect of this program. The Congress of the United States has appropriated 542.5 million dollars for allocation to the States. The States and local communities have matched to date-more than 500 million dollars of these Federal funds with about 950 "million dollars with State and local sponsors funds. Thuslv we have today a program of Federal, State and local cooperation directed at achieving more equitable distribution of hospital and health services, The total cost of the construction approved under the Hi3.1-Burton @gram now exceeds one billion 45o million. dollars, Some of the positive accomplishments of the Hin-Burton Program are: 1. The establishment of an o@erky system of Drovid@ hospitals and related health services throueh the development of-State-wide hospital @ns. For the first time as a result of the Hil'6-Burton Program an orderly mwvey,and appraisal of the Nationle,existing hospital and public health center resources is available, The plans developed by the States are in essence 4L blue print for furnishing hospital services to the people-of the nation,, Presented - Association of State Planning Agencies - Hill-Burtoh Program 4th Annual Meeting, Philadelphia, Pe=sylvania, September 15,, 1952. These plans dglinea-ta hospital service areas within a State and establish a priority -3tr,.ictiz:@v for construction. Priorities are essentially based on it L , 'ties whe the .native noed "a ',he construction of hosio a' aci@- re greatest need for them is demonstrated. 2* The interest of local citizens have-been stimulated to provide-good hospital ser-%,ices for their comun;,'-v The Comunity of Lebanon, Oregon, represents the 1,OCOth completed Hill-Burton project to be opened and placed in operation. As of August 31, 1952., 1,,850 projects have been approved. These projects provide 89,000 hospital bads, 350 public health centers and 15 State health laboratories. The States set the Federal share to be made available a- nnually for ,each project within a State, Ths percentage varies from State to State between 33-113 percent to 66-2/3 percent for the Federal share, The txact percentage is a determination by each State within the limitations provided by the basic Act. The hospital needs of communities differ from State to State. In many. States conventional acute general hospitals are the rule while in others public health centers containing a small number of beds for emergency care purposes have been constructed, In Mississippi there has been constructed small health canter-@and clinic combinations. The primary aim of these health center-clinic combinations is to orovide to remote rural locations health department facilities and facilities for treatment of emergency and obstetrical cases, In addition, in quite a few States we find combination hospitals and health centers being regarded as the answer to local needs. These latter are a recognition that modern medical care requires a fusion of curative and preventive services into a program of health maintenance for the individual and the mass of individuals. 3 3! $tate-widb.plannin@.for hos-pital and health services has been stimulated. .7he Hill-3,arton @rogram @.as led the States to better planning on a state-wide basis; into better thinking concerning coordination and integration of hospital services between the smaller hospitals and the teaching centers in the university and the health center as a basic part of the program. State plans as they have developed have incorporated the philosophies and techniques of regionalization. Programs of coordination such as are demonstrated by the Rochester Plan in New York., the Bingham Associates Plan in liew England, the Kansas Plan, the Virginia Plan,, and the Georgia Plan., among others,, are vital demonstrations of ways to accord better patient care in smaller hospitals. 4. Tho Hill-Burton Program has stimulated-the development of-=roved architectural design. @lod*rn hospital design is based on functional planning. This has led to a better intogration.of hospital services within the hospital. The inclusion of group thinking (on the needs of a hospital) by those working in hospi@ has improved design. It should be emphasized that hospital care is-not static and therefore hospital architecture is constantly in a state of flux. This is good, Po@r a moment on the direct effects of the modern role of radio-active isotopes in the field of medical practice in regard to hospital design, Again, the role of television and other electronic devices in the educational field is changing our hospitals administrators? and hospital architects' ideas in planning the teaching centers, This is all good. It demands an a7.s,-&.reness by s2l concerned in providing modern facilities for hospital services. 4 5,. The Hill-Burton ftogram is accomplishing: basic-levislative purroses b7 reducina areas of @eatest @et need in a@-,cordini ,z hos r)ital services in these areas. The first State plans showed 594 areas with no existing acceptable hospital facilities, This included about 25 percent of the 2,300 general hospital service areas in existence. These 594 areas contained 10 million people or 7 percent of the total population. A review of the current State plans shows 254 areas remaining with no existing acceptable hospital facilities. These 254 areas now constitute only 11 percent of the 2,300 hospital areas. These 254 areas include a populat ion of 4.4 iaillion people or only 3 percent of the total population. The first State plans indicated a need for 34,000 beds in the 594 areas @with no acceptable beds, In the 1952 State plans this has been reduced to a need for 14,000 beds. These statistics are those of the States themselves and not Federm. figures.- 6, indirect result stemmine from the Hill-Burton Lrogram has been the number of States with new licensure laws. Forty three of the 53 States and Territories now have licensors laws covering general hospitals, S3'.xteen States and Territories had licensure laws when the Hi3l-Burton law became effective in 1946, Fifty three States and Territories have regulations for operation and maintenance of general hospitals, The impetus of Hill-Burton on such regulations and standards is reflected by the fact that since the enactment of Public-law 725 (79th Congress) in 19/.6., 48 States have revised these regulations, 5 7, The Hill-Biirton prozram has -provided: a. A 4ide ice.tter of new nro.-ects th--@il,,zlicut th,? Fifty-two (52) percent of the projects are 'located in southern States,, the area which still has one of the hi@st remaining total populations living in areas without any hospital faci'k--@lies, b, Ccnstruction of new Drojects in com=@ties with no prior hospital facilities. , Of the nearly 700 completely new general hospital projects mre than 400 or approximately three-fifths are located in areas which had no hospitals prior to I'Li3.1-Burton, about 3.40 or an additional one-fifth are located in areas which had only non- acceptable facilities. a. Construction in re@ional centers to SUT)rort the hospital and health facilities in outlying-areas. Two hundred and six projects adding more than 16,000 beds igmminting to nearly 350 million dollars worth of construction, of which the Federal government contributed ne arly 2-15 million, have been constructed in base areas. These projects include the construction of teaching facilities in nineteen University medical centers in Alabama, Arkansas, Florida@ Georgia@ Illinois,. Indiana, Y.ansas, Maryland, Y4=esota, Mississippi, Missouri, Nebraska, North Carolina, Oklahomag Pe=sylvaniat South @olina,, Texas,, Virginia, and Washington. Federal aid through Hill-Burton funds has also been granted to a teaching hospital,. training interns and residents in nearly every area of the couly rya 6 .ean,s of attractjM-a ana holclinp- health Personnel in co=runitie-so @iysicians have been retained in rural co,==ities and medi@ and other hea,!-.h -erzc,.ine'L '.@,ave been attracted to areas where no pk@isic4.an or hospi- tal was previously available. in the State of Georgia 43 p@icians have located in 13 communities which have built hospitals under this progr=. In- Mississippi there are 7 com=ities where 12 physicians are reported to have located in these areas because of these new hospitals. Similar statements can be made in regard to Kansas,, Nebraska., Iowa, Washington, Michigan,, Maine, New )%:dco, in fact nearly every area of this country* No Hill-Burton project is closed because of @k of personnel necessary to its operation. Several of the 1,000 completed projects are not able to render all the services intended because of personnel lack, but anticipate that in time these personnel gaps will be eliminated and the full range of services as planned will be accorded. -9. The najorill of Hill-Burton Pro-iects al iMs envisioned la the Con2rese-are @ hospitals in tLq no bo areas,' This . turned- out to be ntial as -these @pitals cold be reF,,@ed as the evacuation dest@tions of the @eer pol2atia_l @t &=As bombina-sbould an international con- f:Lict occ=. Of the lt850 projects 70 percent are general hospitals. Of theset nearly 1,300 general hospitals 58 percent or 750 projects are located in co@ties of less than 10.,OOO population. are other ac=Mlisbments @which are of benefit to the individual citizen'in acq@g better hospital care, but If we are to be objective we must list also the major criticims encountered in such an extensive programs 7 Some of these ares 1. Too much concentration in the constnicti(.-,n of v-er--ral hosoitals has Seventy percent of the pro4ects, 80 percent of the beds, 85 -ercent of Federal funds have gone-into construction of new general hospitals and tle addition$ remodeling or replacement of @sting general hospitals. This is not difficult to understand as such projects as mental, tuber- culosis, or chronic hospitals do not have the same appeal as that offered by the general hospital. There should be a better balance of all categories of hospitals and the general hospital should be more truly genera. than they now are* The Hill-Burton program currently represents about one-third of all hospital construction in the counter. At the =rent level of construction (including construction outside of Hill-Burton) the gap between beds needed and beds existing for general hospitals could be closed in about five years; for mental and tuberculosis hospitals in less than 25 years; and for chronia' hospitals in less than 170 years. These estimates make no provision for e g population or for uncorrected obsoleseense over future years. It should also be stated that the basic bed formula stated in Public Law 725 79th Congress., was used for computation of these rough estimates. 2. Concentrat on on the construct-' rural i taLs. a. Tnree-fifths of the new -eneral hospitals are located in ties with less than 5,000; only 7 percent are in cities with 50,,OOO or more. b. What this criticism overlooks is that about one-fourth of the Federal funds for new hospital construction goes into the @er facilities. Better than half of Federal monies provided for new 8 construction ascists facilities with 100 or more bedsp and that furth,--r=re more ti.Lan 80 percent of the Federal funds going into ,-r@,4,ects i_rtvol-iing additions or alterations of @sting L'acilities is going into hospitals with 100 beds or more. The Federal funds are roughly,about equally divided between the construction of new projects and additions and alterations, When one realizes that only 20 Percent of tiie new projects have 100 beds or more, and that two-thirds of the additions and alterations are hospitals with 100 beds or more it becomes evident that 3 out of every $10 expended for hospital construction goes,into improvements needed to maintain but not to add beds., Hill-Burton has fairly creditably met its fundamental legislative purpose in constructing hospitals in areas where no facilities were available and in keeping existing.plants in operation. 3. Not encuF-h priorit a. Federal aid has been granted to: projects for the construction of teaching hospital facilities in university medical centers in 19 States amounting to about 24 million do3-lars4, b. Hi3.1-Burtonlaid has gone to nearly 170 hospitals (91 million dollars) which can be considered teaching hospitals in the sense that they are approved for training interns and residents in various medical specialties# 4. Althoueh the RUIgspphies of 2D eLrp d aLik. PLanp -4@l jA ViLeg-t iD@V@ _jhey a.. The criticism seems valid because of the lack of truly good demonstrations of effective coordination. 9 b, Fi=cial support for such demonstrations are lacking. c, The result of application of the mechanism of regionalization would 'ce ',-lo -educe overlapping Patterns of nare4 d, Attention needs to be given to the,relative merits of =all hospitals built as independent institutions as contrasted to a branch of a complete medical center* The Hunterdon Medical Center, Flemington@ New Jersey, and its association with a great medical teaching center in New York City is an example. There are others in the country. 5* No& enough congtrug&ign or Rsychia_tXic, chronig,-K& tube=-UD@ ILn a in 68,000 general beds have been added, but only 7 percent are tuberculosis, mental or chronic beds. If the essential function of the hospital is to serve the health needs of the community, not merely the sick, and we are to develop a truly preventive approach, more general hospitals public health center c @ inations need to be developed, 60. Tgo Mgh stani 9L Lack of now approaches in recent years has been noted.. Certain essential changes in hospital design await @,stalization of he t care practices Will.the future hospitals in order to be the true health center of its commmity have large out-patient diagnostic facilities? 7a, Me-chgoin for =iving at the co=le@ ob@in* There have been some critical comments based on practices'in some States of being "loose" in defining "areas". "referral beds", "Acceptable beds", "bed-death ratiot', and also in "transferring beds for planning purposes 10 from rurnl to urban areas, without any objective information". The role of the Federal F Government in regard to the degree of responsibility which is I it appropriate @O.- 'O a@@ Z.,l ll-'-nter.@e@gi or assia-L,4Lng" in ',he develon- ment of State Plans and the subsequent revisions occasionally is the subject of c to In order to eliminate as much as possible any unnecessax7 criticism it is b6lieved,that some solutions that can be offered are: a. Mandatory public hearings on annual State Plans and revisions. b. More careful definition of bed capacity in Public Health Service Health Grants Manual. 0. Regulation changes with respect to the distribution of pool beds* de Regulation changes defining the maximum number of beds to be allowed for planning purposes. S. aeqtlL thnean where, ke@ ip , eaes k.rathgr@__ This difficulty springs from the fact@tl,.at co ties may be unable t-o raise the necessary sponsors" share. A solution may be increased incentives for projects in poor areasj, with high priorityl by the use of the @able grant procedure within a State for allocation of Federal funds* This type of procedure is now in use In only four States. A refinement of areas to eli-ninate poorly delineated areas might solve part of the problem# Not all areas as now designated can be regarded as valid areas. Some are clearly open to question and have already been discussed with the States in the annual plan review. On the other hand some genuine areas have been @eted into,larger areas. Some States have classified all the beds in an area as acceptable despite evidence to the contrary. These aspects too, have been discussed in annual plan reviews. Substantial advance has been made in reducing areas of ireatest needi So,-ae of the factors affecting the apparent rate of progress in eliminating areas of c,.-ea@@es+v need are: a. The total funds available through Hill-Burton assistance and also outside the program. b. The degree to which high priority projects were sponsored and approved. It should be noted that in a number of States there has been substantial non-Federally aided hospital construction. In California only about one-sixth of the dollar value of hospital construction is Hill-Burton aided. In Iowa, one-half of the hospital beds added by new construction or remodeling have been in larger comunities without Hi3.1-Burton-assistanceg The Iowa Agency points out that "without specific powers to prevent construc- tion of hospital projects not receiving aid) there is nothing the (Iowa) Division can do to.prevent overbuilding hospital facilities which comoly with licensure requirements". On the other hand North Carolina, with annual State appropriations as large as the Federal allotments, has markedly reduced Its "zero areas" (from 40 to 19) because only limited local funds have been necessary to launch a project. Today 14 States and Territories have legislation authorizing some State funds for hospital construction. These are mainly in the South.. plus California and l@oia* Rates of participation vary from token paymn:s 'O as much as 85-pereent of the total cost of construction.. including the com- bined State and Federal contribution 12 - In conclusion two topics seem pertinent, There has be-In considerable. discussion as '!,o ral'-CLity of t'.a6 '-4-mi'@at4,on regarding ase of T@aders-i --,,",Ids for the general. beds (4.5 beds per thousand pomlation); mental beds (5 beds per thousand population); chr6nic beda.(2 beds per thousand population); tuberculosis beds (2a,- beds per average annual death over a sample 5 year period 1939-44). It is believed that a change just for change sake is not desira'cl---* Any chanc-a, and one may be indicated.. properly should come as the result of carefully made studieso Some of these are now being conducted especially in the tuberculosis area. The final topic to be considered is that of an extension of the -Hi3.1-Burton program beyond the present statutory limit of June,30, 19550 The bed need in 1946 was estimated at 900,000 for all categories. Today our present bed need is estimated bylthe States in their State Plans as 880.000 despite the 1 billion 450 million dollars of construction under .the Hit-Burton program and the addition of 89,000 beds and 350 public health centers. It is readily seen that the existing 1,018,000 beds and 6p3OO non-Pederal.hospitals represent only 51+ percent of our Nation'$-need. The increasing anmw2 population, the attrition rate from obsolescence and a from fire$ wind and earthquake.. the fact that in our e@ting hospital plant 40 percent of our hospitals are over forty years'of age, and the changing trend of medical care all point to the fact that currently as a Nation we are just "treading water"',, The need for a continuation of the Hi]2- Burton program is great. Perhaps the extended program for Hospital Survey and Construction should be more flexible to permit greater emphasis on teaching facilities or replacement of obsolescent hospitals or parts of 13 hospitals, tb allow emphasis on most needed types of hospitals, and to allow a -.art-@ --,-@,hasi-s @f a Abater de--ee .@.or '-,he more densely -c-laiated areas oi the country. the Hil3.-Burton Program-has done part of a tremendous job of getting hospital facilities into needed areas. The improvement of the quality of hospital care rests not entirely on improved or better facilities but mostly and properly upon those who have the responsibility for guiding it.- the medical profession and their associates. The hospital bed is but a @l of service. Properly placed and properly utilized it will play an important role in maintaining the heiLlth of our people.