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Performance Budget Submission for Congressional Justification

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Testimony on the President's Fiscal Year 1999 Budget Request for AHCPR

John M. Eisenberg, M.D., Administrator, AHCPR

Before the House Subcommittee of the Committee on Appropriations, Departments of Labor, Health and Human Services, Education, and Related Agencies


Contents

Introduction
Challenges Facing AHCPR's Customers
Building the Evidence Base
Measuring and Improving Health Care Quality
Fiscal Year 1999 Budget Request
Initiative To Improve Health Care Quality
Outcomes for the Elderly, Chronically Ill
Children's Health
Clinical Preventive Services
Centers for Education and Research Therapeutics
The Medical Expenditure Panel Survey (MEPS)
Government Performance and Results Act
Conclusion

Introduction

Mr. Chairman and Members of the Committee, I am pleased to be here today for the first time as Administrator to present the President's budget request for the Agency for Health Care Policy and Research (AHCPR). AHCPR's mission is to provide science-based information that will improve decision making at all levels—from patients, to clinicians, to health care system leaders, to public and private policymakers. AHCPR also has been designated by Secretary Shalala as lead agency on quality of care, and health care quality research will be the Agency's highest priority during the next year as our budget request reflects.

Challenges Facing AHCPR's Customers

Our fiscal year 1999 budget request recognizes the need to address the challenges faced by AHCPR's customers. Some of these challenges are long standing. However, new challenges have arisen because of rapid changes in the organization and financing of health care services.

The changing nature of health care delivery forces the health care industry to adapt at every level, and seek out information—based on evidence—that will guide decisionmaking by patients and clinicians, health care system leaders, and public and private policymakers. I cannot overstate the importance of an evidence base for clinical medicine. It gives health care professionals the information they need to make effective, timely diagnoses, and to provide appropriate treatment. Health professionals need to know what works to provide quality health care, and their patients deserve no less. However, while it is good to have a large body of information, we need to provide this information in a useful format.

We need an infrastructure in place that will provide patients with information on health care quality. This information should include outcomes of treatments, patient assessments, and other quality indicators. In addition, we also need to track our progress over time to provide policymakers with the ability to assess the quality, cost, and access to care in America.

The changes to the health care system have created new structures, processes, and settings in which care is delivered. Health care system leaders need answers to questions such as:

  • What is the impact on quality?
  • What happens to patients' access to services, the cost of those services, how they are used, and what are the outcomes of patients who use the services?

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Building the Evidence Base

I see AHCPR's clinical research as a continuum. First, we build the science base by conducting health services research that serves as the foundation for improved care. Second, we translate and disseminate the research in a format that can be used in clinical practice. Third, we evaluate the translation and dissemination of that research to make sure that it has reached the relevant audiences and is used appropriately.

I'd like to tell you about some of AHCPR's current work that promotes the development and use of science-based information, and then talk about what we hope to initiate in 1999 with your help.

AHCPR's sponsored research attempts to determine what works and doesn't work for a wide variety of common, costly medical conditions and treatments and for which there is substantial variation in practice. For example, an AHCPR-supported study found that treating common ear infections in children with antibiotics, such as amoxicillin instead of more costly choices, could save millions of dollars a year without changing recovery rates. Middle ear infection is the most frequent reason for giving antibiotics to children in the United States, and no single antibiotic has been found to be superior in treating this condition. However, costs of antibiotics vary widely, from under $3 dollars to over $60 for a course of treatment.

Last fall, AHCPR named 12 Evidence-based Practice Centers, or EPCs, each of which will develop a scientific analysis, in the form of a report, of the evidence of the effectiveness of a various treatments, technologies, or procedures. This analysis will then be used by health care organizations, medical societies, physician practices, and others to develop their own quality improvement tools, including guidelines, quality improvement programs, and performance measures.

For example, an EPC at the Blue Cross and Blue Shield Association Technology Evaluation Center is studying testosterone suppression treatment for prostatic cancer. At present, prostate cancer is the second leading cause of cancer deaths in U.S. males with estimated costs of $1.5 billion per year in direct medical expenses and substantial costs expended in the Medicare Program. Clearly, we need to know what works and what doesn't work for this condition. Other EPC topics include rehabilitation of persons with traumatic brain injury, depression treatment with new drugs, and treatment of attention deficit-hyperactivity disorder.

In addition to EPCs, AHCPR, in partnership with the American Medical Association and the American Association of Health Plans, is establishing a National Guideline Clearinghouse™ (NGC) to provide one-stop-shopping for best practices in clinical care. The NGC will make existing clinical practice guidelines available to every clinician, patient, health system leader, and policymaker who can use a computer.

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Measuring and Improving Health Care Quality

Recent public debate has focused on the concern of many Americans that ongoing changes to the health care systems are having an adverse impact on the quality of health care, particularly for people with chronic conditions.

AHCPR's activities are helping to build the knowledge needed to measure and improve health care quality accurately and reliably. We are working to refine existing measures and develop new measures that accurately reflect the changing health care system. An important component in this effort to develop and test valid measures is to anticipate future measurement needs. The goal of our efforts is to begin to identify and develop the "next generation" of quality measures for certain conditions, population subgroups, particularly vulnerable populations such as the chronically ill, and in the full spectrum of treatment settings, such as rehabilitation and home care.

An important component of improving the quality of health care services is giving patients the information they need to make informed choices about their health care coverage, physicians, and treatment options. The White House recently announced the release of AHCPR's Consumer Assessments of Health Plans (CAHPS®) survey, a series of questionnaires designed to be used by public- and private-sector health plans, employers, and other organizations to survey their members and employees. The information from CAHPS® questionnaires can lead to informed choices based on quality.

We know that consumers select health plans based on the recommendations of their families, friends, and colleagues at work. While this is a good start, CAHPS® provides information on the experiences of hundreds of people who already are in a particular plan. This provides a view of a health plan that is more representative and more reliable than what can be captured by the opinions of a few individuals. Since CAHPS® allows for comparisons among similar and across different types of plans (managed care vs. fee for service), consumers will be able to get a complete picture of the what each option provides and how it stacks up to what else is available.

CAHPS® already is being used by a wide range of private sector organizations, including Ford Motor Company's Department of Health Care Quality, which is testing it in two markets. The surveys have been used by more than 20 States, including California, Maryland, New Jersey, Washington, Texas, and Florida. The White House also announced last Friday that HCFA will begin fielding a CAHPS® survey, developed in partnership by AHCPR and HCFA, to assess the quality of care in Medicare managed care plans.

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Fiscal Year 1999 Budget Request

In fiscal year 1999, AHCPR requests a total of $171.4 million, an increase of $25 million over the fiscal year 1998 appropriation. This level of support will provide for new extramural research in areas such as outcomes and effectiveness research; measuring quality; research on health care markets, organization and delivery; evidence-based practice research; pharmaceutical research; minority health; women's health; cost effectiveness analysis; and health services research training.

The increase of $25 million over the fiscal year 1998 appropriation will support the Secretarial Initiative to Improve Health Care Quality; outcomes research for the elderly, chronically ill, and children; development of two Centers for Education and Research Therapeutics as directed by Congress in the FDA Reform Bill; and support for two Clinical Prevention Centers. Support will also continue, at a total of $27.8 million, for the Medical Expenditure Panel Survey (MEPS).

[Select for budget details from the Justification of Budget Estimates for Appropropiations Committees, Fiscal Year 1999.]

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Initiative To Improve Health Care Quality

In addition to the fundamental health services research on health care quality that will be carried out through investigator-initiated projects, in the fiscal year 1999 request, AHCPR will provide $15 million to support the Secretary's Initiative to Improve Health Care Quality. Through this initiative, the entire Department will collaborate to pursue five goals:

  1. Making information on quality easier for consumers to use.
  2. Strengthening value-based purchasing by the Department.
  3. Improving the quality of health care services delivered directly by Department programs.
  4. Expanding research that improves quality.
  5. Measuring national health care quality as reflected in our budget submission.

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Outcomes for the Elderly, Chronically Ill

In fiscal year 1999, AHCPR will focus its research on the elderly and chronically ill population. The increasing growth of the elderly population in this Nation will have a dramatic impact on the cost and organization of health care, particularly in the area of chronic illness and disability. New health services research totaling $5 million for this important population will be focused on the cost, quality and outcomes of care for chronic illness and disability.

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Children's Health

AHCPR is also focusing its research on health care for children. The passage of SCHIP provides a landmark opportunity to assist States and communities through the development and dissemination of tools to measure and improve the quality of care for children in this country. The $2 million included in the fiscal year 1999 request will provide support for applied research and demonstrations on the most important challenges in children's health. In addition, AHCPR will support research and evaluations of various state and local approaches to implementing the SCHIP legislation. AHCPR will disseminate research findings and provide technical assistance to States, providers, and communities about what works in improving children's health.

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Clinical Preventive Services

Providers and patients have great interest in the full range of appropriate preventive care. These interventions have the potential to improve the health of the American people, but we need to know what is effective. In fiscal year 1999, we will support major new assessments of preventive services to provide information that will help decisionmaking about preventive services. AHCPR also will sponsor the Put Prevention into Practice initiative, which creates and disseminates tools for providers, health systems, and patients to improve delivery and receipt of these preventive care recommendations.

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Centers for Education and Research Therapeutics

The recently enacted Food and Drug Administration Modernization and Accountability Act of 1997 includes new responsibilities for AHCPR. A level of $1 million will allow AHCPR to support the establishment and operation of two Centers for Education and Research Therapeutics (CERTs). The CERTs will increase the awareness of new uses and risks of medical products, and help prevent adverse effects of medical products and the consequences of these effects.

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The Medical Expenditure Panel Survey (MEPS)

Funding for MEPS continues to be one of our highest priorities in fiscal year 1999 with a total of $27.8 million being allocated. I am pleased to announce that the first MEPS data became available in April, 1997 with subsequent releases thereafter. This data fulfilled one of our performance plan objectives, as required by Government Performance and Results Act (GPRA) of 1993, to release and disseminate MEPS data and information products in timely manner.

[Select for information on MEPS from the Justification of Budget Estimates for Appropriations Committees, Fiscal Year 1999.]

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Government Performance and Results Act

The timely release of MEPS data is only one objective in AHCPR's overall fiscal year 1999 Performance Plan as required by GPRA. The fiscal year 1999 President's budget request for AHCPR incorporates the first annual performance plan required under GPRA. The fiscal year 1999 performance goals and measures are detailed in our performance plan and are linked to both the budget and to the HHS GPRA Strategic Plan (transmitted to Congress on September 30, 1997). Performance targets in the plan are partially a function of resource levels requested in the President's budget, and could change based upon final congressional appropriation action. We look forward to Congress' feedback on the usefulness of our performance plan as well as to working with Congress on achieving the goals laid out in our plan.

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Conclusion

Mr. Chairman, the health care marketplace continues to change at a rapid rate, and timely and accurate information from AHCPR-supported research is critical to maintaining high-quality health care for all Americans. Approval of AHCPR's budget request for fiscal year 1999 will ensure that unbiased, reliable information on the cost-effectiveness of treatments for specific conditions, as well as strategies to translate the best science into routine practice, are implemented and result in high-quality care at an affordable cost. My colleagues and I will be happy to respond to any questions that you may have.

[For more information on the budget, select Justification of Budget Estimates for Appropropiations Committees, Fiscal Year 1999.]

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Current as of March 4, 1998

 

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