Health Systems Agencies (HSAs), the new regional health planning agencies established by the National Health Planning and Resources Development Act of 1974, have as their major goals quality, accessibility, continuity and cost containment. One of the tools for cost containment available to HSAs is their active participation in the statewide certificate-of-need (CON) program. To help anticipate how HSAs may play their CON roles, this article reviews the CON decisionmaking processes of two Comprehensive Health Planning (CHP) agencies, the predecessors of HSAs. While most CHPs lacked specific health plans and powers, the two California agencies examined have had both regional plans and roles in CON programs comparable to the present HSAs'.

Our focus is on the decisionmaking process rather than the effectiveness of CON programs. A simple descriptive model is developed based on the assumptions that the planners seek satisfactory, rather than optimal solutions and that the data available to them are extremely limited. The cases analyzed suggest that, while most projects exceed the bed need standards, institutions were almost always able to demonstrate a need through various special circumstances. Once a need has been shown, the agency was able to deny an application only if a better alternative were available.

This study suggests two approaches to improving regional health planning decisionmaking. First, identified needs can be better met either by increasing the agency's ability to generate alternatives or by encouraging health facilities to submit competing applications. Second, a regional health care budget would force the agency to make choices among competing needs.

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