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Justification of Budget Estimates for Appropriations
Committees, Fiscal Year 2000
The mission of the Agency for Health Care Policy and Research (AHCPR) is to support, conduct, and disseminate research that improves the outcomes, quality, access to, and cost and utilization of health care services. This mission, which focuses on the effectiveness and value of health care in daily practice, is unique and complements the biomedical and behavioral research responsibilities of the National Institutes of Health. The products of the Agency include knowledge that supports decisionmaking to improve health care and tools that can improve quality and reduce costs.
Health care in 1998 is very different from 1989 when the Agency was created, and the Agency has adjusted its agenda and priorities to meet the new challenges, while continuing the charge set forth by Congress. To this end, AHCPR has focused it's priorities on three primary customers: clinical decisionmakers, health care systems leaders, and public policymakers, each of whom need information to enhance their contribution to improve the quality of care in this country. AHCPR serves its customers with research on outcomes, quality, cost, use, and access.
Providing objective, science-based, timely information to health care decisionmakers—patients and clinicians, health system leaders, and public policymakers—is the challenge that faces health services research and AHCPR in the next century. Meeting this challenge depends heavily on the continued collaboration and communication between the Agency and its partners. The Agency's goal is to conduct and support high-quality, relevant research that is translated and disseminated to improve the quality of heath care services, and ultimately, the public's health.
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AHCPR is guided by and directly supports two of the strategic plan goals of the Department of Health and Human Services: Goal 4—Improve the Quality of Health Care and Human Services; and Goal 6—Strengthen the Nation's Health Sciences Research Enterprise and Enhance Its Productivity.
Specifically, AHCPR's research is
designed to focus on four areas:
- Improving clinical practice. Clinicians, patients and health
care institutions need information about what works, for whom,
when, and at what cost.
- Improving health care systems. Medical practices, hospitals
and other institutions, health networks, and plans need
information to improve the health care system's capacity to
deliver quality care.
- Tracking the Nation's progress. Policymakers at all levels
of government as well as private-sector policymakers need
more information to monitor and evaluate the impact of system
changes on access, cost, and use of health care.
- Improving activities that support all areas of research. These include
dissemination; cost effectiveness analysis; priority
populations including minority and ethnic groups, women,
children, and the elderly; and health services research
All four areas of research are targeted through our budget activity
research on Health Costs, Quality, and Outcomes (HCQO). HCQO funds
research and development of tools to improve the functioning of the
health care system. Whether at the level of an individual patient
and clinician confronting discrete care choices, a medical director
of a managed care plan caring for a defined population, a State
official addressing the health needs of entire communities, or
public and private purchasers seeking value for their health care
dollar, health services research answers the enduring central
questions: What works? Under what circumstances? For which
conditions? At what cost?
For details from the justification, select Research on Health Costs, Quality, and Outcomes
AHCPR's Medical Expenditure Panel Survey (MEPS) provides public and
private-sector decisionmakers with the ability to obtain timely
national estimates of health care use and expenditures, private and
public health insurance coverage, and the availability, costs, and
scope of private health insurance benefits among the U.S.
population. Using the information from MEPS, AHCPR provides
analysis of changes in behavior as a result of market forces or
policy changes on health care use, expenditures, and insurance
coverage; develops cost/savings estimates of proposed changes in
policy; and identifies the impact of changes in policy for key
sectors of the industry (e.g., primary care)and important subgroups
of the population (i.e., who benefits and who pays more).
For details on MEPS from the justification, select Medical Expenditure Panel Survey.
Program Support provides support for the overall direction and management of
the AHCPR. This includes the formulation of policies and program
objectives; program planning and evaluation; grants and contracts
management; resource management; and administrative management and
Select for details about Program Support.
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Fiscal Year 2000 Request—Closing the Gap
The fiscal year 2000 budget reflects a major new commitment on the part of AHCPR to ensure that the knowledge gained through health care research is translated into measurable improvements in the American health care system. The key to the Agency's fiscal year 2000 budget proposal is to support new research, and to translate research into practice. It represents the culmination of a 9-month process of linking the Agency's planning processes to budget planning and performance management through the Government Performance and Results Act (GPRA).
In the last 3 years, the Agency has been asked increasingly to demonstrate the impact of its work on improved health care. While the examples of significant contributions are numerous (select for How AHCPR's Research Helps People), the fact remains that much of the Agency's research has focused on providing an accurate description of what actually works, and hence what does not work, in health care; developing tools to measure the costs, quality, and outcomes of care; studying the impact of important trends in health care; and identifying important unanswered questions. Thus, the work has focused more on the development of knowledge, leaving translation, adoption, and measurable impact to other forces. However, the work of research is only "half done" with the publication of findings in a major research journal.
What is clear today is that we now have knowledge of what can be improved and can commit the Agency to a significant investment in promoting the adoption and use of research findings and being able to demonstrate that the potential benefits demonstrated by the research are actually achieved in daily practice. This must be done while continuing to support new research on priority health issues and the development of new tools, so that in the future this new knowledge and new tools can also be translated and implemented to produce improved health care.
AHCPR's fiscal year 2000 budget theme is "Closing the Gap" and consists of three major priorities:
These priorities are framed to close four gaps:
- First, we need to use the results of what we have learned to close the gap between what we know and what we do today in health care practice.
- Second, we need to fund research to close the gap between what we know now and what we need to know to further improve care in the future.
- Third, we need develop the tools that enable us to close the gaps between the questions confronting decisionmakers at all levels in the system and the information that is available to them.
- Finally, we need to apply all of these strategies to close the gap between minority populations and whites in the quality, outcomes, and access to care.
In addition, the Agency's request was developed to specifically respond to the recommendation of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
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The AHCPR Portfolio: A Pipeline of Investment
The fiscal year 2000 proposal also reflects a "pipeline" of activities that together build the infrastructure, tools, and knowledge for improvements in the American health care system. Biomedical science establishes the foundation for determining which interventions can work under ideal circumstances. We now know that many additional steps are required to assure that what can work does work for all individuals. The necessary steps include scientific assessment of opportunities for improvement, development of tools to measure performance, and strategies for improving performance on a broad scale, in partnership with the key change agents in today's health care system: purchasers, health plans, and clinicians. These steps are contained in our concept of a pipeline.
|PRIORITY I ||PRIORITY II||PRIORITY III
|New Research on Priority Health Issues |
| New Tools and Talent for a New Century |
| Translating Research
This pipeline begins with the funding of new research that answers important questions about what works in American health care (New Research on Priority Health Issues). This is the essential knowledge base that investigators create which enables us to understand the determinants of the outcomes, quality and costs of care as well as identify instances when care falls short of achieving its intended outcomes.
The second section of the pipeline is the creation of tools to apply the knowledge gained in the first investment (New Tools and Talent for a New Century). Here, the work of researchers is more applied and translates new knowledge into instruments for measurement, databases, informatics and other applications that can be used to improve care.
The final section of the pipeline is where these two investments come together to enable research and demonstrations to translate the knowledge and tools into measurable improvements in the care Americans receive.
This approach is comprehensive and successful in yielding important advances. Recent successes with this approach include the Agency's work in two critical areas within chronic disease prevention: the treatment of diabetes and the treatment of asthma (select for details).
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Summary of Fiscal Year 2000 Priorities
I. New Research on Priority Health Issues ($10.055 million)
This fiscal year 2000 priority will fund health care research to close the gap between what we know now and what we need to know to further improve care in the future. This priority will be more focused than past efforts to respond directly to the priority needs of Medicare and Medicaid. Through past investments we have identified which questions need to be answered, and learned that to shorten the time between knowledge acquisition and behavior change, we also have to change the way in which research is conducted.
Thus, the key features of this priority will include:
- Explicit identification of conditions that are responsive to national priorities.
- A commitment of sufficient funds to each area to yield substantial advancements in 3 to 5 years.
- A coordinating strategy to link researchers with the intended users of the findings from the outset.
- Establishment of links between researchers and important implementation opportunities in the health care system to maximize rapid adoption.
In each priority area, a comprehensive portfolio of research will be funded that builds on the investments to date and addresses the Agency's goals: outcomes, quality, and cost, use and access.
Select for more detail on Priority I
II. New Tools and Talent for a New Century ($13.200 million)
A new century brings with it dramatic changes in our health care system. Most important among these are the power of purchasers in a market system, the promise of information technology applications in all aspects of the organization and delivery of services to populations and individuals, more involvement of patients in shared decisionmaking with health professionals, and the increasing role of States in determining the future of health care. However, we know much less about the impact of these forces on the quality and outcomes of care than we do about the biological basis of health and disease.
Compared with any other industry in America, health care lacks the basic information and tools to understand, trend, and forecast future events. Science has not been able to provide policymakers with the answer to even to the most basic question: "How are we doing?" There is no set of "leading health quality indicators" comparable to those in economics or manufacturing. The report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, Quality First, noted this as one of the Commission's major findings. Decisionmakers and public and private purchasers lack the fundamental information tools they need to monitor, much less influence, these outcomes.
This priority will develop the tools to enable us to close the gaps between the questions confronting decisionmakers at the State and Federal level and the information that is available to them. In consultation and partnership with decisionmakers, AHCPR will craft a system of sentinel indicators and an "early warning system" that can be used to track and understand changes in quality at the National, State, and community levels. Through a continuing dialogue with key decisionmakers including the Health Care Financing Administration (HCFA), Federal and State legislators, employers, health systems, consumer and patient advocacy groups, and providers, the Agency will identify major decisions that they are facing or will face with significant potential for impact on quality, outcomes, access, and cost of health care.
Select for more detail on Priority II.
"This Commission has drawn a road map for higher quality across American health care. Above all, our Nation must develop uniform national standards so that health plans can compete on quality, not just cost; and so that health care consumers can judge for themselves. This is the best way to assure quality health care for all Americans."
—President Clinton, from the President's Remarks on Health Care Quality, March 13, 1998
III. Translating Research into Practice ($13.500 million)
The past decade has seen formidable breakthroughs in science, but little of this new knowledge has been implemented into daily clinical practice. One consequence of this gap between what we know and what we do is wide variation in the quality of care, which results in excess morbidity and mortality and billions of dollars in wasted spending. The need to address this variation is coupled with the fact that research consistently shows that it has taken between 6 and 10 years for clinical practice to adopt new knowledge for conditions that affect the majority of patients in this country. We must use the results of what we have learned to close the gap between what we know and what we do today in health care practice.
This priority will shorten the time lag in implementing new knowledge by using the fruits of the last 10 years of investment in health care research to systematically identify aims for improvement, establish public-private partnerships, support practice networks, and fund demonstration grants to systematically test strategies for implementing findings, and to measure the success of strategies for facilitating change. The end result will be quantifiable improvements in health care in America, measured in terms of improved quality of life and patient outcomes, deaths averted, and dollars saved.
Select for more detail on Priority III.
"We need to practice, not just publish, better patient care."
—Senator Bill Frist
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In addition to the three priority areas, specific priorities and ongoing commitments in the fiscal year 2000 request have been designed to support fiscal year 2000 Secretarial Initiatives as follows:
- HHS Race and Health Disparities: ($10.150 million)
- Long-term Care: ($ 1.500 million)
- Violence Against Women: ($ 1.080 million)
- Chronic Disease and Prevention: ($ 9.000 million)
Race and Health Disparities
The HHS Race and Health Disparities Initiative focuses on eliminating the differences in outcomes and health status for minority populations in six clinical areas. These disparities generally are not due to gaps in knowledge regarding disease processes, but are the result of provider factors, patient factors, and organizational factors that impair the implementation of existing knowledge.
In fiscal year 2000, AHCPR is requesting funding to support programs which are important in helping the Department achieve its goals for the Racial and Health Disparities Initiative. Funding to address minority populations in connection with the Initiative are incorporated into the three priorities of the Agency fiscal year 2000 budget proposal detailed earlier.
Priority I. New research on priority health issues. The purpose of this priority is to determine what we need to know to improve care further and also includes an explicit focus on racial/ethnic minority populations. The proximate goal of the Racial and Health Disparities Initiative (eliminating the disparities by the year 2010) necessitates a change in the way research is conducted in order to incorporate findings into practice more quickly. Of the funding requested by AHCPR for this priority area, we have allocated $4.50 million for the priority areas of the Racial and Health Disparities Initiative. The funding will support targeted activities in health services research on minority populations and support the development of centers doing research on minority populations. Both of these activities will target the Racial and Health Disparities Initiative as the research focus, and assure that we gain new knowledge about the factors that affect the quality, outcomes, cost, and access to care for minority populations. (Priority I investment: $4.50 million)
Priority II. New tools and talent for a new century. Each of the three steps in this priority area will include activities in support of the Racial and Health Disparities Initiative. Step 1, which enhances existing databases to improve decisionmaking in the health sector, will oversample subpopulations of racial/ethnic minorities to enable assessment of the quality of care they receive and comparisons with majority populations. Step 2 will develop new tools to improve quality and will specifically fund grants to create tools that are culturally sensitive and address the needs of minority populations. Step 3 includes a specific focus on training minority and other investigators to address issues for minority populations and will work with Historically Black Colleges and Universities (HBCUs) and Hispanic Serving Institutions (HSIs). (Priority II investment: $1.65 million)
Priority III. Translating Research into Practice. This priority will close the gap between what we know and what we do. Of the $13.50 million in the priority, $4.00 million will be specifically allocated to address issues for minority populations. Prior work by the Agency has identified many of these differences between what works for the majority and what works for ethnic minority populations, and this effort will explore reasons for the disparities and ways of eliminating them. Through the creation of laboratories for change, the Agency will build partnerships between health care delivery sites and academic researchers, addressing the specific conditions of the Racial and Health Disparities Initiative. AHCPR's priority will support the design of systematic interventions to determine which approaches are most effective, as well as promoting innovation in the implementation of research findings and the practice of evidence-based medicine. A priority will be determining to what extent general strategies need to be modified to improve care for minority populations. (Priority III investment: $4.00 million)
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AHCPR continues to support both intramural and extramural research projects to improve the outcomes, quality, and cost, use and access to long term care services. An aging population is increasing the demand for these services, while cost pressures may be affecting the quality of care provided. Efforts to assess the quality of care given to elderly populations have a different focus than efforts to measure quality of care for the population at large. Much of this difference stems from the fact that care provided to elderly patients is often aimed at maintaining or improving functioning rather than curing disease. As a result, long-term care outcomes measures generally focus on assessing patients' ability to function rather than on ascertaining the presence or absence of disease. Measurement of long term-care quality is complicated by the fact that many elderly are cognitively impaired.
As part of its fiscal year 2000 request, AHCPR has included a number of activities which will support the Secretary's Initiative to improve long-term care. Priority I includes new research on conditions of particular importance to the Medicaid population. Priority II will invest in the development of tools to measure the quality of care in institutional settings, including consumer and patient experiences with that care. (Total investment: $1.50 million)
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Violence Against Women
Physicians, nurses and other health care providers confront the daily consequences of domestic violence in the form of broken bones and other trauma, chronic pain, insomnia, substance abuse and depression. Injuries tend to be recurrent and the medical care costs for a domestic violence victim are variously estimated at two to five times those of an average patient.
Many of the most innovative medical care approaches to the prevention, screening and treatment of domestic violence are recent and have been put in place by organized health care systems. The emergence of organized systems, which have the ability to follow groups of victims over time, has created a new capacity for study of the outcomes and effectiveness of clinically-based screening and treatment programs. In addition, new primary care practice networks are developing and also provide an opportunity to study improved strategies for the identification and referral of domestic violence patients.
Research which examines the value of domestic violence screening and treatment programs are imperative. A recent Institute of Medicine study of the effectiveness of prevention and treatment programs found almost no scientific basis for assessing interventions in use. Its 1997 report noted that a review of the literature published between 1980 and 1996 found only eight studies assessing interventions that met their minimum standards for scientific rigor. One was an AHCPR-supported study at Group Health of Puget Sound related to training for health care providers.
AHCPR proposes two new research initiatives which address the role of the health care system in screening and treating domestic violence in clinical settings:
- Assessing the outcomes, effectiveness and cost-effectiveness of clinical treatment programs for domestic violence victims. Despite the growing investments of public and private organizations in domestic violence treatment programs, there are few well-designed studies of whether such programs work to improve the health of victims of violence. Virtually no longitudinal studies of the outcomes and effectiveness of interventions exist. This is a critical gap because domestic violence tends to be a recurrent problem and the success of programs may only be evident over time; conversely, programs which bring about initial improvements may not result in sustained progress.
In this initiative, the Agency would work with health plans, clinicians, and researchers to support up to three large-scale, longitudinal studies of the outcomes and effectiveness of medical interventions designed to identify and treat domestic violence victims. Collaborating health plans would be required to share the costs of the project and provide administrative support for data development and collection.
Advocates and health plans would understand whether domestic violence interventions which are based in the health care system are effective and, if they are, which components are most critical to their success. As cost-effective models are identified, health plans will have a strong incentive to put additional programs in place. In addition, the improved understanding of the quality parameters and essential components of programs would provide an evidence base for new performance measures for health plans. ($1.0 million)
- Violence Against Women (VAW) Fellowship Program. AHCPR proposes to develop a new VAW Fellowship Program. It would provide promising academic and clinical professionals with an opportunity to expand their knowledge and understanding of violence against women issues through a structured development program. The Fellowship program would be broadly designed to serve HHS as a whole, and fellows would apply to any HHS Agency able to support the fellowship.
Fellows will be offered a well-designed mentorship and training program. The goal is to broaden their background and enhance their leadership skills through the research, development, analysis, or other work they undertake on programs intended to prevent and reduce violence against women. The first AHCPR VAW fellow would work on health services research issues related to the outcomes, effectiveness and cost-effectiveness of the violence prevention and treatment programs available in organized health care settings.
AHCPR is requesting $ 0.08 million to support basic development and implementation of the VAW Fellowship Program and one AHCPR fellow.
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Chronic Disease and Prevention
AHCPR's fiscal year 2000 request directly supports the goal of the chronic disease prevention initiative to "meet the challenge of preventing chronic diseases and promoting the quality of life in an aging population." Most of the burden of illness and most of the medical care costs borne by our society are due to chronic diseases and their risk factors. Chronic diseases are leading causes of disability and death in the United States, and treatment for people with chronic conditions accounts for three quarters of national health care costs. Activities along the entire pipeline of investment in the fiscal year 2000 request are directed to improving the knowledge, tools, and health care practices to manage chronic illnesses:
- New Research on Priority Health Issues. Overall, the new research funded under Priority I will include a substantial emphasis on chronic illnesses given the criteria to be used to determine areas of investment (high cost, high prevalence, relevance to Medicare and Medicaid, etc.). Specifically, the investment in research on pharmaceuticals and the establishment of the new Centers for Education and Research on Therapeutics will include studies on the effectiveness, cost-effectiveness, and quality of prescribing practices for chronic illnesses. These will include a focus on the management of poly-pharmacy and the impact of pharmaceutical interventions on the functional status and quality of life of chronically ill adults and children. In addition, new studies on improving health outcomes for minorities will build on prior work of this Agency through the Minority MEDTEP Centers. These Centers focused on a variety of chronic illnesses, including diabetes and hypertension. Finally, the investment in research to evaluate the impact of managed care and other changes in the organization and financing of care will specifically include studies on care for chronic illnesses for adults and children. (Priority 1 investment: $2.00 million)
- New Tools and Talent for a New Century. Priority II will build new tools to improve quality of care and quality of life, including clinical quality and patient satisfaction measures. Specifically, new measures for chronic illnesses in adults and children will be developed. The latter are particularly lacking at this time. These measures will be for assessing the quality of care across settings of care, including ambulatory, hospital, rehabilitation, and long-term care settings. Expansion of the Healthcare Costs and Utilization Project (HCUP) and tool development linked to this data set will permit States to track their progress in the management and costs of chronic illnesses that frequently lead to hospitalization. AHCPR has developed 33 Quality Indicators based on hospital discharge data that States can use to track and compare hospital quality and community access to primary care. Three of these indicators focus specifically on short- and long-term complications of chronic illness, and four others are indicators of avoidable hospitalization for chronic conditions. Also, under Priority II, the agency will extend the database to an additional four States and to emergency rooms and other sites outside of the hospital so that clinicians and policymakers will be able to track progress across the continuum of care for chronic illness. Finally, the enhancements proposed to the Medical Expenditure Panel Survey (MEPS) under priority II will allow the collection and analysis of data on the quality and costs of care for a number of chronic illnesses, including diabetes and cardiovascular diseases. (Priority II investment: $3.00 million)
- Translating Research into Practice. Priority III will include in fiscal year 2000 a substantial focus on chronic illness. Much of the research of the Agency in the last decade has demonstrated how care for many chronic illnesses falls short of including those treatments that we know work. Whether we are looking at care after heart attacks in the elderly, the appropriate management of asthma, or periodic screenings for the complications of diabetes, we find that patients are often not receiving effective and cost-effective care. In 1998, AHCPR began two initiatives that will lay the groundwork for making substantial improvements in the care of chronic illnesses in adults and children. First, AHCPR initiated a $7.00 million partnership with the American Association for Health Plans Foundation (AAHPF) to study the impact of various features of health plans on the quality and outcomes of care for chronic illness including diabetes. Overall, the projects will be looking at features of managed care that produce better quality and outcomes for people with diabetes and other chronic conditions. Second, the Agency funded the first set of evidence reports to synthesize what is known about the effectiveness and cost-effectiveness of interventions for high priority conditions. Twelve reports have been commissioned to date. Eight of these were on chronic illnesses such as stable angina, depression, and dysphagia in the elderly. (Select for information on Evidence-based Practice Centers.)
As part of Priority III, AHCPR will build on these investments to accelerate quality improvement through demonstrations of effective strategies to translate research into practice in the care of chronic illnesses. Implementation of known, effective practices is essential in the prevention of the complications and cost of chronic illness. Much of the care for chronic illnesses is in the ambulatory settings. This is where effective primary care can reduce hospitalizations and unnecessary costs and improve outcomes. AHCPR will establish at least one primary care or managed care network centered on chronic illness management. Using this network and investigator initiated grants and demonstrations, AHCPR will fund a coordinated set of projects to: (1) determine effective strategies to change practitioner behavior in the care of chronic illnesses in adults and children; (2) improve the quality of care during transitions of chronically ill individuals between acute and long term care settings; (3) improve care through the appropriate use of specialists; and (4) test these strategies among vulnerable populations including racial and ethnic minorities, the poor, and those over 75 years. (Priority III investment: $4.00 million)
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Medical Expenditure Panel Survey
The fiscal year 2000 request includes $36,000,000 for the Medical Expenditure Panel Survey (MEPS). Continued funding for the ongoing MEPS effort begun in fiscal year 1994 totals $29,000,000, an increase of $1,200,000 over the fiscal year 1999 level. The additional $7,000,000, included in Priority II, will expand the clinical power of the database through additional information from medical records and household interviews and will increase the capacity of MEPS through increased sample size and new questions, including a more extensive module on children.
All of the MEPS components will be heavily engaged in survey-related activities directed to the following tasks: data editing, imputation, data preparation and data processing, development of estimation weights and variance estimation capabilities for the component surveys, preparation of public use tapes, and development of analytical and methodological reports. (Select for more information on MEPS.)
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The fiscal year 2000 request of $206,255,000 is an increase of 20 percent over the fiscal year 1999 President's Budget. The request provides a significant increase in our investment to close the gap between what we know and what we do in health care. To accomplish our goals, AHCPR will increasingly use funding mechanisms rarely employed before. The use of program project grants and demonstration projects also represents a shift in our approach to health services research: AHCPR has shifted to a quantifiable, result-focused research orientation. Select for detailed information on AHCPR budget policy as well as fiscal year 2000 request funding summaries.
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Current as of February 1999