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Testimony on the President's Fiscal Year 2000 Budget Request for AHCPR

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

Before the House Appropriations Committee, Labor and Health and Human Services Subcommittee


Contents

Introduction
AHCPR's Research and Its Impact
   AHCPR's Impact on Patients and Clinicians
   AHCPR's Impact on Health Care Systems and Policymakers
Update on Fiscal Year 1999
Fiscal Year 2000 Request
   Priority I: New Research on Priority Health Issues
   Priority II: New Tools for a New Century
   Priority III: Translating Research Into Practice
Conclusion

Introduction

Mr. Chairman and members of the committee, I am pleased to be here today to present the President's fiscal year 2000 budget request for the Agency for Health Care Policy and Research (AHCPR). I want to introduce to you Dr. Lisa Simpson, AHCPR's Deputy Administrator, and Ms. Rita Koch, Chief of AHCPR's Financial Management Staff.

Before I proceed, I would like to thank this committee for recognizing the importance of our research by providing AHCPR with the President's budget request in fiscal year 1999.

Mr. Chairman, when I appeared before this committee last year, you asked me how AHCPR's research was helping to improve people's lives. This is an extremely important question, and we have taken it to heart. In fact, your question on how our research helps people has become a touchstone at AHCPR, and we have geared our research agenda toward answering this question. I would like to report to you today on how our past research has improved health care and how the Agency has fashioned its budget priorities to do an even better job of meeting this challenge through the fiscal year 2000 request.

The Government Performance and Results Act (GPRA) has provided us with a basis for measuring the performance of how our research helps our customers. AHCPR's GPRA plan focuses on the end users of our research. Their input has driven the development of our research agenda.

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AHCPR's Research and Its Impact

AHCPR's Impact on Patients and Clinicians

The Consumer Assessment of Health Plans (CAHPS®), one of the most widely used of our products, is providing people with a tool to help them decide what health plan best meets their health care needs. The CAHPS® will make information on the quality of health care available to 90 million Americans in 1999. It is being used by 20 States, 10 employer groups, a wide range of health plans, and the Ford Motor Company. The Health Care Financing Administration (HCFA) has also used CAHPS® to survey Medicare enrollees in managed care plans to assess their experiences. The U.S. Office of Personnel Management will use CAHPS® to report consumer assessments of their health plans to Federal employees.

AHCPR's sponsored research led to the development of new technology to help emergency room doctors improve their decisionmaking about whether to hospitalize or discharge patients with chest pain. The study combined a diagnostic tool with a traditional instrument—the electrocardiograph or "EKG"—used in emergency departments. Because of this diagnostic aid, an estimated 200,000 people could be spared a hospital stay they didn't need and more than 100,000 people could be spared an unnecessary admission to a Critical Care Unit. The potential savings associated with this instrument are estimated to be $700 million a year. This new technology has been adopted by a renowned private-sector corporation for development and marketing. (Select for press release.)

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AHCPR's Impact on Health Care Systems and Policymakers

AHCPR's research provides public and private policymakers with information to help them make informed health care decisions. For example, based on AHCPR's research, Medicare's Peer Review Organizations (now called Quality Improvement Organizations or QIOs) have implemented 73 projects in 42 States to increase anticoagulation therapy for Medicare beneficiaries who have suffered from a stroke. The percentage of Medicare patients discharged on anticoagulation therapy has increased from 58.4 to 71.1 percent. HCFA estimates that this improvement has prevented up to 1,300 strokes.

AHCPR research has also developed a new way to measure disease severity of diabetic patients, based on a combination of patient-reported symptoms and other factors. This work has now become part of the Diabetes Quality Improvement Program, a common set of diabetes quality measures being developed jointly by HCFA, the Department of Veterans Affairs, the Department of Defense, and other professional groups, including the American Diabetes Association. The goal of the program is to improve care and prevent later problems, such as kidney disease and skin ulcers, that are currently all too common in diabetic patients.

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Update on Fiscal Year 1999

Before I discuss the President's fiscal year 2000 request, allow me to touch on our major fiscal year 1999 initiatives. As you may recall, the Agency was provided new authority under the Food and Drug Modernization Act to establish Centers for Education and Research on Therapeutics (CERTs). These Centers will fund research and education on the use of approved drugs, the prevention of adverse drug reactions, elimination of pharmaceutical errors, and the appropriate use and dosage of specific drugs in special populations such as women, children, minorities, and the elderly. Too often patients are not aware of the dangerous side effects of misusing medication by either mixing medications or overusing a particular medication. For example, research has shown that the over prescribing of antibiotics can lead to resistance to an antibiotics therapeutic effects.

In fiscal year 1999, we will spend $2 million to support CERTs demonstration projects. We believe this is a down payment on an investment that will reap large returns. Experts estimate that the CERTs program is a relatively small investment which has the potential to save a part of the $20 billion that the GAO has estimated is lost each year from misuse of medications.

We have also begun to implement the Department's initiative to improve health care quality. We are pursuing a two-part strategy to improve health care quality in America. We are supporting targeted research and investigator-initiated research, to focus on developing quality information for two purposes. The first is choice, for example, helping people choose the best health plan or doctor. The second is improvement, such as increasing screening for chlamydia to help prevent infertility in women.

To date, we have issued five Requests for Applications (RFAs) aimed at improving and measuring the quality of care that Americans receive. In a departure from our previous research in this area, these RFAs will explore strategies for moving research findings and evidence-based tools (clinical practice guidelines, practice parameters, quality indicators and continuous quality improvement initiatives) into clinical practice.

It is our goal to build on the success of quality improvement tools, such as the Health Care Cost and Utilization Project (HCUP) Quality Indicators, to help hospitals, physicians, and nurses measure and improve the care that patients receive. Recently, the Healthcare Association of New York State used HCUP Quality Indicators (which include measurements of outcomes, use and access to primary care) developed by AHCPR to generate a comparative performance report for member hospitals.

One of our accomplishments that I am pleased to report is that the National Guideline Clearinghouse™ (NGC) went live on the Internet on December 15, 1998. A formal launch of the Clearinghouse was held in January. We developed this in collaboration with the American Medical Association and the American Association of Health Plans.

The NGC will serve physicians, nurses, and other health care providers as a comprehensive resource on evidence-based clinical practice guidelines. To date, we have over 500 clinical practice guidelines submitted by over 67 guideline developers.

New guidelines will be added to the NGC weekly. We already have heard from a number of those who we consider our customers including—physicians, patients, and medical librarians—about the usefulness of NGC. The layout of the Web site and the standardized abstracts and tables allow users to quickly compare similar guidelines by different organizations . The tables provide information on the major areas of agreement and disagreement among guidelines to help users make informed selections.

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Fiscal Year 2000 Request

I would like to turn to our request in fiscal year 2000, which totals $206 million, an increase of $35 million over the fiscal year 1999 appropriation. We at AHCPR are making a major new commitment to ensure that the knowledge gained through health care research is translated into measurable improvements in the health care system. The key to the Agency's fiscal year 2000 budget proposal is to translate research into practice by converting new knowledge into action to improve health care.

The fiscal year 2000 proposal reflects a "pipeline" of activities that together build the infrastructure, tools and knowledge for improvements in the American health care system. At the front end of the pipeline, we identify where care falls short of achieving appropriate outcomes, where there are gaps in care, or quality of care is low. We discover new ways of measuring quality, the outcomes and effectiveness of care, as well as its cost, use, and access. In the middle of the pipeline, we support research to develop instruments for measurement and other tools that can be used by our customers to improve and measure the quality of care its cost and peoples access to the care. Finally, and most importantly, we support translation of the tools and science into everyday practice.

The fiscal year 2000 request also includes $10 million for the Department's Racial and Ethnic Disparities Initiative, with support included in each of our three priorities.

Priority I: New Research on Priority Health Issues

In fiscal year 2000, we request $10 million to 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.

For example, despite the large number of studies and guidelines defining the management of heart attacks, many patients (often patients of vulnerable populations) still receive sub-optimal care. AHCPR research found that elderly patients who received "beta blockers" (drugs used to lower the heart rate) following a heart attack were rehospitalized 22 percent less often than nonrecipients and the mortality rate was 43 percent lower. However, only 21 percent of eligible patients were using beta blockers.

The National Committee for Quality Assurance (NCQA) used the findings of this study as the basis for changing the performance measurement for beta blocker use after heart failure to include patients over 75 years of age in the most recent version of the Health Plan Employer Data and Information Set or HEDIS 3.0 (a set of standardized performance measures designed to assure that purchasers and consumers have the information they need to reliably compare the performance of managed care plans). HEDIS 3.0 is being used by the Health Care Financing Administration to assess the quality of care provided by Medicare HMOs.

This priority will be more focused than past efforts to especially respond directly to priority needs of Medicare and Medicaid. Through past investments we have identified which questions need to be answered and discovered new ways to measure care and the factors to lead to high and low quality, high and low access, and high and low cost. The research has also learned that to shorten the time between knowledge and behavior modification, we also have to change the way in which research is conducted to maximize adoption of the findings into practice.

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Priority II: New Tools for a New Century

In fiscal year 2000, we request $13.2 million to invest in the tools that we will need to monitor the quality of care Americans receive, and to invest in the talent to meet the research needs for improving and measuring quality.

Compared to any other industry in America, health care lacks the basic information and tools to understand, trend, and forecast future events. Science has not yet 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 the leading economic indicators which measure the state of our economy. Decisionmakers and public and private purchasers lack the fundamental information tools they need to monitor, much less influence, these outcomes. Many of our customers, particularly hospitals and managed care organizations, tell us that they are trying new quality improvement strategies which are based on word-of-mouth anecdotes, with little knowledge or likely impact on patient care. Can you imagine if economic decisions were based on anecdotes?

This priority will develop the tools to provide health care providers and policymakers with information to gauge the quality of care that Americans are receiving. We will make this information accessible by building on two of our existing databases, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (a database which provides hospital data in 22 States). Findings from AHCPR's past medical expenditures surveys have yielded information for Medicare program policymakers about potentially inappropriate drug prescribing for elderly patients, as well as the characteristics of elderly people who are disabled. Currently, MEPS tracks the extent to which elderly people have employer-based or other private insurance, in addition to Medicare coverage, providing valuable information for policymakers struggling with the implications of changes to the Medicare programs, as well as on cost and access to health care services to all Americans.

In consultation and partnership with health care decision-makers, AHCPR will expand the MEPS and HCUP databases by crafting a system of sentinel indicators that can be used to track and understand changes in quality at the national, state, and community levels. This is an exciting new initiative which will give us information on the cost and quality of care across the nation; information that we have never had in the past.

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Priority III: Translating Research Into Practice

The past decade has seen formidable breakthroughs in science, but little of this new knowledge has been implemented into daily clinical practice. For example, research has shown that the use of corticosteroids reduces infant mortality and disabilities in preterm babies. However, the drugs were being underutilized by the medical community. AHCPR supported research to increase the use of corticosteroids to prevent the complications that often come with preterm pregnancy. According to a study published in the Journal of the American Medical Association, this intervention resulted in a 33 percent increase in the use of corticosteroids.

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 the majority of patients in this country.

In fiscal year 2000, we request $13.5 million to shorten the time lag in implementing new knowledge by using the fruits of the last 10 years of investment in health care research to dramatically shorten this time by assisting doctors, patients, health systems and purchasers to use new knowledge in their daily health care activities. Specific activities will include demonstrations to improve quality of care for minority populations with specific emphasis on diabetes and asthma. We will help states with improving health care quality, by conducting a workshop on asthma disease management through AHCPR's User Liaison Program. Other grants and demonstrations will address errors in medicine, including errors in prescribing drugs. AHCPR will also work with the Centers for Disease Control and Prevention (CDC) to educate providers about the dangers of antibiotic resistance.

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.

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Conclusion

Mr. Chairman, I want to thank the committee for supporting the President's budget request for AHCPR in fiscal year 1999, and I respectfully request the committee's consideration of President's request of $206 million for AHCPR in fiscal year 2000. Thank you.

[For more information on the budget, select Justification of Budget Estimates for Appropropiations Committees, Fiscal Year 2000.]

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Current as of February 1999

 

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