[House Hearing, 106 Congress]
[From the U.S. Government Publishing Office]



 
   REAUTHORIZATION OF THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH

=======================================================================

                                HEARING

                               before the

                            SUBCOMMITTEE ON
                         HEALTH AND ENVIRONMENT

                                 of the

                         COMMITTEE ON COMMERCE
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED SIXTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 29, 1999

                               __________

                           Serial No. 106-29

                               __________

            Printed for the use of the Committee on Commerce

                    ------------------------------  





                     U.S. GOVERNMENT PRINTING OFFICE
56-608 CC                    WASHINGTON : 1999





                         COMMITTEE ON COMMERCE

                     TOM BLILEY, Virginia, Chairman

W.J. ``BILLY'' TAUZIN, Louisiana     JOHN D. DINGELL, Michigan
MICHAEL G. OXLEY, Ohio               HENRY A. WAXMAN, California
MICHAEL BILIRAKIS, Florida           EDWARD J. MARKEY, Massachusetts
JOE BARTON, Texas                    RALPH M. HALL, Texas
FRED UPTON, Michigan                 RICK BOUCHER, Virginia
CLIFF STEARNS, Florida               EDOLPHUS TOWNS, New York
PAUL E. GILLMOR, Ohio                FRANK PALLONE, Jr., New Jersey
  Vice Chairman                      SHERROD BROWN, Ohio
JAMES C. GREENWOOD, Pennsylvania     BART GORDON, Tennessee
CHRISTOPHER COX, California          PETER DEUTSCH, Florida
NATHAN DEAL, Georgia                 BOBBY L. RUSH, Illinois
STEVE LARGENT, Oklahoma              ANNA G. ESHOO, California
RICHARD BURR, North Carolina         RON KLINK, Pennsylvania
BRIAN P. BILBRAY, California         BART STUPAK, Michigan
ED WHITFIELD, Kentucky               ELIOT L. ENGEL, New York
GREG GANSKE, Iowa                    THOMAS C. SAWYER, Ohio
CHARLIE NORWOOD, Georgia             ALBERT R. WYNN, Maryland
TOM A. COBURN, Oklahoma              GENE GREEN, Texas
RICK LAZIO, New York                 KAREN McCARTHY, Missouri
BARBARA CUBIN, Wyoming               TED STRICKLAND, Ohio
JAMES E. ROGAN, California           DIANA DeGETTE, Colorado
JOHN SHIMKUS, Illinois               THOMAS M. BARRETT, Wisconsin
HEATHER WILSON, New Mexico           BILL LUTHER, Minnesota
JOHN B. SHADEGG, Arizona             LOIS CAPPS, California
CHARLES W. ``CHIP'' PICKERING, 
Mississippi
VITO FOSSELLA, New York
ROY BLUNT, Missouri
ED BRYANT, Tennessee
ROBERT L. EHRLICH, Jr., Maryland

                   James E. Derderian, Chief of Staff

                   James D. Barnette, General Counsel

      Reid P.F. Stuntz, Minority Staff Director and Chief Counsel

                                 ______

                 Subcommittee on Health and Environment

                  MICHAEL BILIRAKIS, Florida, Chairman

FRED UPTON, Michigan                 SHERROD BROWN, Ohio
CLIFF STEARNS, Florida               HENRY A. WAXMAN, California
JAMES C. GREENWOOD, Pennsylvania     FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia                 PETER DEUTSCH, Florida
RICHARD BURR, North Carolina         BART STUPAK, Michigan
BRIAN P. BILBRAY, California         GENE GREEN, Texas
ED WHITFIELD, Kentucky               TED STRICKLAND, Ohio
GREG GANSKE, Iowa                    DIANA DeGETTE, Colorado
CHARLIE NORWOOD, Georgia             THOMAS M. BARRETT, Wisconsin
TOM A. COBURN, Oklahoma              LOIS CAPPS, California
  Vice Chairman                      RALPH M. HALL, Texas
RICK LAZIO, New York                 EDOLPHUS TOWNS, New York
BARBARA CUBIN, Wyoming               ANNA G. ESHOO, California
JOHN B. SHADEGG, Arizona             JOHN D. DINGELL, Michigan,
CHARLES W. ``CHIP'' PICKERING,         (Ex Officio)
Mississippi
ED BRYANT, Tennessee
TOM BLILEY, Virginia,
  (Ex Officio)

                                  (ii)


                            C O N T E N T S

                               __________
                                                                   Page

Testimony of:
    Eisenberg, John M., Administrator, Agency for Health Care 
      Policy and Research........................................     4
    Kahn, Charles N., III, President, Health Insurance 
      Association of America.....................................    30
    Lindberg, Brian W., Executive Director, Consumer Coalition 
      for Quality Health Care....................................    36
    Mahan, Charles S., Dean, College of Public Health, University 
      of South Florida...........................................    34
    Woolley, Mary, President, Research!America...................    25
Material submitted for the record by:
    American Academy of Family Physicians, prepared statement of.    47
    Association of American Medical Colleges, prepared statement 
      of.........................................................    47

                                 (iii)

  


   REAUTHORIZATION OF THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH

                              ----------                              


                        THURSDAY, APRIL 29, 1999

                  House of Representatives,
                             Committee on Commerce,
                    Subcommittee on Health and Environment,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m., in 
room 2322, Rayburn House Office Building, Hon. Michael 
Bilirakis (chairman) presiding.
    Members present: Representatives Bilirakis, Deal, Ganske, 
Cubin, Bryant, Brown, Deutsch, Green, Barrett, Capps, and 
Eshoo.
    Staff present: Jason Lee, majority counsel; Thomas Giles, 
majority counsel; Penn Crawford, clerk; John Ford, minority 
counsel, Karen Folk, minority professional staff.
    Mr. Bilirakis. The hearing will come to order.
    Good morning. I now call to order this hearing on 
reauthorization of the Agency for Health Care Policy and 
Research. Today we will hear testimony from the administrator 
of the agency as well as experts from both the public and 
private sectors. I would like to thank all of our witnesses for 
their willingness to testify on such short notice and for the 
cooperation of the ranking member, Mr. Brown, and the minority 
staff in helping us prepare for this hearing.
    Working on a bipartisan basis, I am hopeful that we can 
pass legislation to reauthorize the agency this year. This 
agency serves a critical function in efforts to improve the 
quality of health care in our Nation. It directly funds the 
collection and analyses of critical health data needed by 
Congress to make sound decisions on health care access, quality 
and cost effectiveness issues. And equally important, it 
provides technical assistance to private sector organizations 
that seek its expertise to support their initiatives.
    I would note that one of our witnesses today played a key 
role in the agency's creation. As minority counsel of the Ways 
and Means Health subcommittee, Chip Kahn spearheaded the 
legislative effort to establish this agency through the Omnibus 
Budget Reconciliation Act of 1989.
    And I want to extend a special welcome to Dr. Mahan, dean 
of the College of Public Health at the University of South 
Florida in Tampa. He is also the director of the Lawton and 
Rhea Chiles Center for Healthy Mothers and Babies. Dr. Mahan 
will describe the Chiles Center's efforts to overcome barriers 
to access to preventive health care through a public-private 
partnership. He will also explain the potential role of the 
Agency for Health Care Policy and Research in achieving that 
objective.
    Again I want to thank all of our witnesses for their time 
and effort in joining us. I look forward to their testimony on 
how reauthorization of this agency can improve the quality of 
health care nationwide and would now yield to Mr. Brown.
    Mr. Brown. Thank you, Mr. Chairman, and special thanks to 
John Eisenberg and our other distinguished panelists. Tapping 
into an expanding agency, AHCPR, is an opportunity to do 
something legislatively that is unequivocally positive for the 
future of health care in this country. Success or failure of 
health care financing and delivery hinges on three variables, 
access, quality and cost. These variables are obviously 
interdependent.
    Optimizing access and quality is a process of spending 
limited dollars in ways that reaches as many people as possible 
with the most effective, efficient care as possible. The work 
that AHCPR does is fundamental to this process. It is the 
agency that evaluates the current systems so that we can 
improve it. With health care dollars as scarce as they are, 
this is a crucially important role. AHCPR conducts and supports 
health services research and communicates the results of that 
research to the health care community and to the public.
    It sounds dry, but it translates into tangible improvements 
into public health, fewer wasted dollars in policy changes 
grounded in knowledge rather than simply wishful thinking. 
Through initiatives such as Friendly Access, which Dr. Mahan 
will discuss, AHCPR also helps the Nation expand its reach to 
deliver care to disenfranchised populations.
    We know that an estimated 2 to 3 million children eligible 
for Medicaid coverage have not been enrolled in the program. 
These children fell through the cracks. AHCPR's research and 
collaborations like Friendly Access, that help us get care to 
these children and our hard-to-reach populations, are a solid 
investment for the Nation. I am pleased to be working with the 
chairman on legislation to reauthorize AHCPR and look forward 
to hearing from our witnesses this morning.
    Mr. Bilirakis. I thank the gentleman. The gentleman from 
Tennessee, Mr. Bryant.
    Mr. Bryant. Thank you, Mr. Chairman. I have no formal 
statement, but I do want to thank both you and the ranking 
member Brown for the work you have done in this, and I 
understand that you will be introducing a bill reauthorizing 
the Agency for Health Care Policy and Research. There will be a 
companion bill filed in the Senate by my colleague from 
Tennessee, Senator Frist.
    I do have other commitments, as all members do; and I look 
forward to hearing the testimony of the panel here. If I am not 
here reviewing their testimony, I might lay out--I understand 
that there is an increase in your budget of $250 million, and 
certainly it would be welcome if you could explain the needs 
that are there--the justification for this increase--and 
certainly I will review that. I have some understanding of why, 
but, again, for the record I would appreciate, in my absence, 
if you would answer that question.
    Again, I thank the distinguished panelists that are coming, 
and again thank our chairman and ranking member.
    Mr. Bilirakis. Thank you. There appear not to be any other 
opening statements from the members of the subcommittee. They 
will be made a part of the record with unanimous consent.
    [Additional statements submitted for the record follow:]
 Prepared Statement of Hon. Tom Bliley, Chairman, Committee on Commerce
    Mr. Chairman, thank you for calling this hearing today. I am 
pleased to see so many distinguished leaders in health policy before us 
to share their views on the value of the Agency for Health Care Policy 
and Research, commonly referred to as AHCPR. It was a decade ago that 
Congress created this Agency to enhance the quality, appropriateness, 
and effectiveness of health care services and access to care.
    AHCPR plays a vital role in empowering consumers with the objective 
information they need to make informed health care purchasing 
decisions. Informed consumers are what drives the private market to 
provide quality services and products. The role of AHCPR as a 
nonpartisan agency able to provide evidence-based science to the market 
place is an invaluable resource from which all Americans will benefit.
    We take great interest in what AHCPR has to say about the best 
practices in medicine, and want to ensure that any legislation that 
moves through this Committee reflects the latest advances in science 
and medicine. In the prevention and early diagnosis of breast cancer, 
an area this Committee has given a great amount of work and attention, 
AHCPR recommended that both physicians and their patients receive 
written notification of the results of mammograms from the facilities 
performing them. When it came time to reauthorize the Mammography 
Quality Standards Act last year, we put the AHCPR recommendation into 
law. As of yesterday, all women will receive letters, or e-mail notices 
about test results as soon as possible, and are encouraged to follow-up 
with their physicians for conditions that cannot be detected by 
mammography.
    This Committee excels in reviewing public laws within its 
jurisdiction in light of advances such as electronic commerce. The 
Committee's approach to AHCPR demonstrates as well. We plan to seek 
authorizing legislation that would give the agency more direction in 
using new technologies including electronic commerce to enhance the 
latest medical breakthroughs in the public and private sectors, to help 
ensure that patients receive high quality, effective and appropriate 
care.
    Once again Mr. Chairman, I applaud you for holding a hearing on the 
reauthorization of AHCPR. I look forward to hearing from our 
distinguished panelists.
                                 ______
                                 
  Prepared Statement of Hon. Gene Green, a Representative in Congress 
                        from the State of Texas
    Thank you for scheduling today's hearing on the reauthorization of 
the Agency for Health Care Policy and Research. I believe their 
research efforts to improve the standards for care will be critical as 
this Committee and Congress moves forward with reforming different 
parts of the health care system.
    I hope today's hearing will lead to legislation that will update 
and strengthen the agency's core mission. Not only should the agency 
retain its research and grantmaking focus to improve knowledge about 
health quality and practices, but we must improve its role and ability 
to disseminate information to health care providers as well.
    The value of the research will only be as great as the number of 
providers who know about it and can apply those results in the 
examination and treatment rooms of America's doctors offices and 
hospitals.
    Clearly, there is a great potential upside to having an agency 
solely dedicated to improving and updating the ``best practices'' 
standards for care. However, I think it is even more important to 
recognize that these developed and widely accepted standards must serve 
as a model or a guide--not an inflexible rule.
    One thing I have learned about health care during my brief tenure 
on the Health and Environment Subcommittee is that there is no such 
thing as always or never. All health care providers must have some 
basic flexibility to model the care of a particular patient to the 
needs of that patient.
    I believe we have an opportunity to substantially improve the 
quality of health care by strengthening the agency to serve as a 
valuable resource and guide to doctors who can then apply the research 
results to the individual needs of their patients.
    Again, thank you for scheduling today's hearing. I look forward to 
hearing from the distinguished witnesses.
                                 ______
                                 
  Prepared Statement of Hon. Anna Eshoo, a Representative in Congress 
                      from the State of California
    Thank you Mr. Chairman.
    There are few things that American people care about more than 
good, quality health care.
    People need to feel confident that they are getting the best 
medical care available by the most knowledgeable, competent 
professionals.
    The Agency for Health Care Policy and Research (AHCPR) helps to 
ensure that they do.
    We've seen it time and again.
    Because of AHCPR research, certain pneumonia patients can now be 
treated in the comfort of their own homes.
    AHCPR research has significantly reduced complications from 
diabetes.
    AHCPR research has improved diagnosis of chest pain, resulting in 
fewer heart attack patients going undiagnosed and a whopping 55% 
reduction in hospital admission rates.
    We are fortunate to live in a country where medical innovation is a 
given. AHCPR is a critical part of the development and application of 
these innovations to create the highest quality health care system in 
the world.
    Thank you Mr. Chairman. I look forward to hearing from the 
witnesses.

    Mr. Bilirakis. Dr. Eisenberg, would you come forward. The 
good doctor is the administrator of AHCPR located in Rockville, 
Maryland. Your written statement is already a part of the 
record. We would appreciate your supplementing it. We will set 
the clock at 10 minutes.

   STATEMENT OF JOHN M. EISENBERG, ADMINISTRATOR, AGENCY FOR 
                HEALTH CARE POLICY AND RESEARCH

    Mr. Eisenberg. Thank you, Mr. Chairman. Thank you for 
enabling us to come and talk to you about the reauthorization 
of the Agency for Health Care Policy and Research. This is our 
10th anniversary year for AHCPR, and in those 10 years the 
agency has matured, I think; and our approach to our plan and 
our approach to our responsibilities has evolved.
    If I were to summarize the entire testimony in one 
sentence, I would say that we are a science partner and that we 
work in collaboration with the public and private sector to 
build the science, the knowledge and information that is going 
to help improve access, the quality and cost of care, and the 
functioning of the health care system in the United States.
    Because my written testimony outlines the details of the 
agency's activities, I would like to focus on four goals. One 
of them is to put our research and our goals into the context 
of what is going on in health care in our country; the second 
one is to discuss the agency's role in health care quality; 
third, outline an example of one new approach to getting health 
care research done and translating it into practice; finally, 
to share some observations on what the appropriate role of our 
agency might be in the future.
    Let me start by talking about how our research fits into 
the context of health research in general. There is a broad 
continuum of health research, and we need a balanced portfolio 
from the most fundamental research to health services research. 
The kind of research that we support, health services research, 
is a companion to the biomedical research agenda.
    Biomedical research in general focuses on mechanisms of 
disease, including basic science. It focuses on clinical 
interventions to understand how well we can translate those 
understandings of basic mechanisms of disease into 
interventions, prevention and treatment and often uses a 
clinical trial, which is an idealized setting, to test whether 
these interventions can work.
    We need to collaborate with our basic science colleagues to 
be sure when the basic science advances are made that we can go 
the next step; that we can assure patients and the Nation that 
it reaps the full rewards of that basic science investment in 
four ways: first, to develop the scientific evidence about when 
those interventions work best in daily practice; second, to 
identify the types of patients for whom those interventions 
work--treatments or preventive or diagnostic services--third, 
to compare their effectiveness and their cost effectiveness 
with existing practices; and last, to translate those research 
findings into improved patient care.
    This research has already started to have an effect on the 
way people in America get their health care. For example, 
urologists in the United States worked with researchers we had 
funded to develop some new ways in which men who have enlarged 
prostates could make decisions about their surgery. This 
research helped the clinicians working with these men to take 
into account the men's assessment of their function, more than 
just physiologic assessment, but what it meant to them as 
individuals, what their health status was, what the likelihood 
was of the risk of surgery, what the likelihood was of a 
benefit from surgery.
    The early results of that study, having been translated 
already into practice, show that men are getting less surgery 
when they use the results of this research, but that they are 
more satisfied and that the costs are down. It is a wonderful 
example of better quality care costing less.
    We have also funded research in the area of clinical 
prevention that has started to make a difference, like the 
assessment of the effectiveness of different kinds of pap 
testing or studies on diagnosing attention deficit disorder in 
children. We support the U.S. Preventive Services Task Force's 
activities as a way of translating those advances in prevention 
through the Prevention Into Practice Program.
    In a nutshell, what we are trying to do is to help the 
practice of health care catch up with the science of health 
care. In addition to the clinical focus that I have been 
emphasizing, the clinical focus on outcomes or the 
effectiveness or the quality of health care, our research also 
helps to develop and translate scientific knowledge about the 
most efficient and effective ways of organizing and financing 
the care and delivering care to people.
    One of the ways that we do this is by supporting a major 
survey called the Medical Expenditure Panel Survey which 
provides the only nationally representative data on 
expenditures and the services that people get, including their 
insurance coverage as well as their out-of-pocket costs.
    These data are already being widely used in the public and 
private sector from think tanks like the Heritage Foundation to 
CBO. We are seeing people recognizing this data base as one of 
the best that the country has to understand what is happening 
in the delivery of health care in this country.
    Anchored to the work that we do, in many ways is the 
comment that Mr. Brown made in his opening statement, when we 
think about our major emphases, we think about three topics: 
one is the outcome of medical care, one is the quality of 
medical care, and one is the cost and use and access to medical 
care.
    We believe that good research can help to inform those 
topics by helping us to understand what works best, under what 
circumstances, with what kind of patients, and determining how 
it compares with existing alternatives.
    If we can answer those questions, then it is going to be 
possible for the practice of health care to catch up with the 
science of health care.
    When we think about who is going to use this information, 
who are our customers, we think about three groups. We think 
about people who need research to make clinical decisions: 
doctors, nurses and other professionals who need the best 
evidence available to guide informed decisions.
    We also think about public policymakers like you who need 
better evidence to drive the decisions that they make, and then 
we think about a third group, and those are the people who work 
in large systems. They may be people in plans or purchasers of 
care, but they are people who need the kinds of evidence that 
we can deliver to help them make better decisions so they can 
get better quality for less cost.
    Mr. Chairman, we think the entire spectrum of health 
services research can contribute to this goal to improve the 
quality of health care. As a clinician, I think about the 
challenge that faced me before I came to the agency in taking 
care of individual patients who came into the exam room. About 
every patient I would ask am I doing it in the right way and 
for the right person, and at the right time.
    I was seeing patients, and like every clinician, there were 
instances when some question would come up and I would ask 
myself, is it that I don't know what is known, or is it that 
nothing is known. Whichever of those two questions a clinician 
asks, our agency can help answer each of those questions. For 
those in which the answer is we really don't know; we don't 
know at all what the answer is to your question, Doctor, we 
think that our agency's research can help to build that 
knowledge base, to close that gap between what we need to know 
and what we know. In addition to that, we can close the gap 
between what we know and what we do. Those are the gaps that we 
think are so important for our agency to close.
    But it is not just clinical questions that our research can 
answer. It is nonclinical questions as well. For example, what 
happens when we offer different kinds of incentives to 
clinicians? How do they respond? How do patients respond when 
they have different kinds of financial incentives or services 
that are available to them? How do we make decisions on what 
kinds of services that we are going to offer?
    Those are questions that we are asking and our researchers 
are answering. Consistent with the Senate's reauthorization 
language, we think that we can provide information to the 
country about how we are doing as a Nation, whether the health 
care that we are providing is getting better, worse, or more 
specifically, in which regions of the country is it getting 
better or worse, and what can we do about it.
    Let me tell you a story about one specific project that we 
do which I think depicts the whole pipeline of research that we 
are concerned about, all of the way from getting new knowledge 
and tools to translating it into practice. It is something we 
call the Consumer Assessment of Health Plan Survey or CAHPS.
    This is a survey that came out about a year ago in its 
first iteration. It is available to plans and purchasers so 
they can collect and compare information on health plans, 
compare them, and make decisions about which ones they would 
choose. Or if you are a plan, determine how you rank compared 
to other plans.
    The story of CAHPS is the story of our working in 
partnership with our customers, asking them what they want and 
need, delivering that and seeing what impact it has.
    So about 4 years ago, we listened to people who make 
decisions about health care plans and we said, what do you need 
to know that you don't currently know about making these 
decisions.
    In a very careful way, we analyzed what needed to be known, 
what was available, and where the gaps were. We then developed 
grants and contracts to organizations outside the agency, 
including some of the best minds in the country, from Harvard 
School of Public Health, the Research Triangle Institute in 
North Carolina, and the Rand Corporation in Los Angeles. We 
asked them to work together as a team, not separate 
investigators, but together as a team to develop this survey, 
this tool, this way of finding out how you can compare plans. 
They came back to us with a sample. We tested it. We evaluated 
it.
    We then made that available to the public, and within a 
year we now can brag that we have Medicare using it, NCQA, 
which is the National Committee for Quality Assurance, the 
Office of Personnel Management, 22 States in their Medicaid 
plans, and a large number of private corporations that are 
using it.
    When we add up the number of people who can compare their 
plans based on how they do in terms of performance for 
consumers, there are over 90 million Americans who have more 
information than they had before. They can now make a decision 
among the plans available to them based on real evidence rather 
than just gossip or anecdote.
    Let me conclude by making five quick observations about the 
reauthorization that is in front of us and the reauthorization 
which the Senate HELP Committee has moved on.
    The first is that we believe that our agency must remain a 
credible scientific research agency, and the Senate language 
helps us to do that. The provisions in that language that help 
us to govern scientific review of our research are critical. We 
use the same system of scientific peer review that our 
colleagues at the NIH use, which helps us to assure that the 
funds we have to support research are going to scientific 
excellence. About two-thirds of our funding goes in grants and 
contracts to researchers around the country, and we

think they are the most talented people that our Nation has to 
offer.
    The second point is that we think that it is clear that the 
agency's research needs to help inform decisions at the 
clinical, system, and policy levels, but we don't make policy. 
For that reason, we are comfortable with the idea of taking 
``policy'' out of the name of the agency because it really has 
led to confusion to some who think that we make policy 
decisions rather than help inform policy researches.
    The Senate Health Committee deleted the word ``policy'', 
added the word ``quality'' to the agency's name, which we think 
is both symbolically important and practically important in 
helping people understand us.
    Third, we believe that our agency should not be a standard-
setting agency. We should support the research that others will 
use in establishing standards. We should not be mandating 
clinical practices. We should not be setting individual 
standards of quality, but we should be, as I mentioned before, 
a science partner.
    The fourth, consistent with the notion of being a ``science 
partner,'' is that we need to develop public-private 
partnerships in every aspect of our work. Our budget does not 
allow us to do anything other than to have partnerships. We 
need to leverage the research that our grantees and our 
contractors get done in order to provide the type of objective 
information that can make our competitive health care 
marketplace function better, and can help the people who don't 
have access to care to get it. When they do get access, our 
research can help ensure that it is high-quality care.
    Finally, we believe that the agency's mission should be 
amended to direct us in the way that the Senate bill does, to 
develop and advance the science of quality measurement and 
quality improvement.
    There are a host of other provisions that I would be happy 
to address now or later. But I principally want to thank you 
for having this hearing and letting us talk but AHCPR's 
reauthorization. Thank you.
    [The prepared statement of John M. Eisenberg follows:]
  Prepared Statement of John M. Eisenberg, Administrator, Agency for 
                    Health Care Policy and Research
Introduction
    Mr. Chairman, thank you for giving me the opportunity to address 
the Subcommittee on the programs and activities of the Agency for 
Health Care Policy and Research (AHCPR). AHCPR's mission is to provide 
good and objective 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's goal is to 
ensure in an increasingly market-based health care system that state-
of-the-science information drives informed decision making.
    AHCPR was established by Congress in 1989 ``for the purpose of 
enhancing the quality, appropriateness, and effectiveness of health 
care services and access to care.'' While we have met this objective 
during the past nine years, we recognize that health care in 1998 is 
very different from 1989, and the Agency has adjusted its agenda and 
priorities to meet the new challenges we face, while continuing our 
charge set forth by Congress. Here are our priorities:

 To conduct and support research on the outcomes and 
        effectiveness of treatments.
 To ensure that clinicians, patients, health care system 
        leaders, and policymakers have the information that will 
        enhance quality of care.
 To identify gaps in access to and use of health care services, 
        achieving value for the Nation's health care dollar, and 
        helping the market and policymakers find ways to address those 
        gaps.
Research That Helps Patients
    Mr. Chairman, before turning to our programs and the way we conduct 
our work, I want to emphasize that this research has already had a 
profound effect on the quality of care patients receive. After all, 
that is the bottom line for our Agency: improving patient health. A 
welcome side benefit, for programs over which you have jurisdiction 
such as Medicare and Medicaid, is that these quality improvements, in a 
surprising number of cases, have also led to lower costs and more 
appropriate use of health care resources. For example:

 Pneumonia. Approximately 450,000 Medicare patients are 
        hospitalized for pneumonia each year. With AHCPR support, one 
        group of researchers developed a way for clinicians to 
        determine which patients with pneumonia can be safely treated 
        at home. This option avoided hospitalization entirely. Studies 
        of health systems that have implemented this decision tool 
        found that it not only reduces hospitalization rates (and, 
        consequently, Medicare costs by 26% in one major hospital) but 
        also that home treatment is preferred by many patients.
 Diabetes. A significant advance in diabetes treatment during 
        recent years has been the demonstration that tight control of 
        blood sugar, using intensive management strategies, reduces the 
        risk of long-term complications from the disease. The intensive 
        monitoring and self-care needed to achieve this, however, is 
        costly and time-consuming for patients and clinicians alike. 
        AHCPR's sponsored research has helped provide the information 
        that diabetics and their health professionals need as they 
        choose the best long-term management strategy for each 
        individual. For type 1 diabetics, for example, AHCPR-funded 
        research has shown that using continuous insulin infusion, a 
        newer mode of insulin delivery, to achieve tighter control can 
        decrease the incidence of ketoacidosis and low blood sugar 
        crisis.
 Heart Attacks. About 1.5 million Americans are admitted to 
        hospitals yearly for serious chest pain. However, of those 
        admitted to inpatient cardiac units, only 30 percent end up 
        with a diagnosis of threatened or confirmed myocardial 
        infarction (MI). This means that 70 percent undergo an 
        expensive workup before they know that they have not had a MI, 
        which translates to more than $3 billion of unnecessary 
        expenditures per year. One group of AHCPR-funded investigators 
        has tested the effectiveness of a chest pain observation unit, 
        located within a hospital emergency department, for patients 
        experiencing a possible MI. This intervention has revealed some 
        very positive effects: fewer heart attacks go undiagnosed 
        compared to hospitals with only inpatient observation units; 
        fewer patients are mistakenly sent home without being observed; 
        there is a 55 percent reduction in hospital admission rates; 
        and there is a 25 percent drop in the average length of stay 
        when an exercise electrocardiogram (ECG) is added to the 
        evaluation procedure. Savings in total hospital costs are 
        calculated at $567 per patient. In addition, patients who 
        receive treatment in the chest pain units are more satisfied 
        with their care, compared to those actually admitted to 
        inpatient cardiac units for observation.
    This research has also had a significant but unexpected impact on 
the way that medical research is conducted and clinical decision making 
takes place. For example, urologists, working with researchers we 
funded, found new ways of determining which men with enlarged prostates 
should have surgery. Health services research shifted the views of 
clinicians by emphasizing the importance of taking into account the 
patient's assessment of how the prostatism affected his ability to 
function, and his assessment of the risk of surgery. Our work has 
broadened the focus for evaluating the success or outcomes of medical 
care from only physiologic measures (such as urinary track pressure 
measures) to include important clinical outcomes, such as patients' 
perceptions of, and preferences for, their ability to function after 
treatment. This research has provided the foundation for truly informed 
patient choice among alternative clinical treatments and higher patient 
satisfaction, as patients become involved to the extent they want to be 
in making these choices. Plus, we have funded the translation of this 
research into practice, and we are already seeing reduced costs along 
with better outcomes through partnership with urologists and their 
patients. We are now funding similar research in other fields, such as 
breast cancer and the care of children.
Quality
    Health care quality is very much in the news and a major issue for 
the Congress. I want you to know that our Agency has played a pivotal 
role in the effort to improve the quality of patient care. We have 
worked closely with all of the major organizations committed to 
improving the quality of patient care, such as the American Medical 
Association (AMA), the Foundation for Accountability (FACCT), the 
National Committee for Quality Assurance (NCQA), the Joint Committee on 
Accreditation of Healthcare Organizations (JCAHO), and many others. And 
we are using every aspect of health services research to address the 
challenges we face.
    But let me start with a basic q uestion: what do we mean when we 
say ``quality?'' At the most basic level, quality means doing the right 
thing, at the right time, in the right way, for the right person. As 
someone who recently left clinical medicine, I am personally sensitive 
to the challenge clinicians face every day in knowing what the right 
thing is, when the right time is, and what the right way is. We are 
using our clinical research, often referred to as outcomes and 
effectiveness research, to address those three questions. And we are 
undertaking efforts, equally as important, to provide clinicians with 
the information they need most: syntheses of what we already know so 
that they can provide care to their patients that takes into account 
the latest findings.
    We are working to develop better information on the quality 
implications of the way we organize, deliver, and reimburse health care 
services. We are developing the measures and tools that will help us to 
assess, compare, and improve the quality of care in different plans and 
settings. And we are working to provide you with a better sense of how 
quality is faring over time, much like the ``leading economic 
indicators'' that provide you with a touchstone for how the economy is 
faring.
    We recognize that our focus on the quality and outcomes of care 
needs to be paired with a focus on issues related to access to that 
care. And we have a special responsibility to address the needs of 
vulnerable populations, who are most likely to face barriers to access. 
Our research has demonstrated that a growing percentage of the 
population are not offered health insurance; that of those offered 
health insurance, a growing number of Americans decline insurance 
coverage; and that even with health insurance, access to quality health 
care is not assured. And the reasons for this lack of access can be 
surprising and disturbing. For example, the Washington Post highlighted 
on its front page several weeks ago an AHCPR-funded study that found 
that primary care physicians were prepared to recommend very different 
courses of treatment for patients of different races and gender who 
outlined identical symptoms. These physicians recommended referrals for 
cardiac catherization only 60% as often for black patients than white 
patients, and there was a clear impact of gender as well. Black women 
were referred only 40% as often. These results are disturbing and 
suggest that we have a broad array of issues to address in ensuring 
access to quality care.
The Conduct and Planning of our Research.
    Mr. Chairman, let me know turn to how we conduct and plan our 
research and our specific research activities. As you well know, AHCPR 
is not a regulatory or enforcement agency, but a scientific research 
agency that sponsors, conducts and translates research. We follow the 
same rigorous evaluation and peer review standards for awarding 
research grants as does the National Institutes of Health. Three-
quarters of AHCPR's research funds are used to support researchers 
throughout the country.
    Since I have been at the Agency, we have been going through an 
extensive planning process. We are consulting our National Advisory 
Council, seeking input from our stakeholders, and welcome advice from 
the Subcommittee. We hope that the reauthorization process will provide 
an opportunity to gain additional insight from you and the other 
witnesses at this hearing as well as strengthen the relationship 
between AHCPR and this Subcommittee. The planning process has focused 
our priorities on four primary customers: clinicians, patients, health 
care systems leaders, and policymakers, each of whom need information 
to enhance their contribution to improve the quality of care in this 
country. In the rest of my testimony, I will describe how we are 
serving our customers with research on outcomes, quality, cost, use, 
and access.
Providing Information that Helps Clinicians Provide Better Care and 
        Patients Receive Better Care
    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.
Measuring Health Outcomes
    First, let me concentrate on how we serve decisionmakers with 
information on outcomes of clinical care. AHCPR's sponsored research 
attempts to answer these questions for a wide variety of medical 
conditions and treatments. The findings of this research have been 
translated into useful tools for every day clinical practice. For 
example, AHCPR sponsored research at John Hopkins University developed 
a visual function index--the VF-14--that measures the effects of 
cataracts on patients' ability to perform 14 everyday activities, 
including reading and driving. The index also allows for comparisons of 
patients' visual function before and after removal of a cataract.
    The VF-14 index is a sensitive and reliable measure of the impact 
of cataracts on visual function. As a result, it can be used to help 
determine the value of cataract surgery for specific patients. In a 
study of more than 500 patients 4 months after cataract removal, 
changes in patients' ratings of satisfaction with their vision 
correlated more strongly with changes in VF-14 scores than with 
traditional ways of measuring changes in visual acuity. Compared with 
other outcome measurements, a changed VF-14 score was also the 
strongest predictor of changes in patients' satisfaction with their 
vision.
    Another tool developed by AHCPR-supported research should have a 
great impact on the quality of care provided to patients who suffer 
heart problems. An outcomes project funded by AHCPR recently found that 
many patients with heart attacks do not receive thrombolytic therapy 
(drugs to dissolve clots inside coronary arteries). Another research 
project at the New England Medical Center led to the development of a 
new tool to care for patients having a heart attack. The tool estimates 
whether a patient is likely to benefit from potentially lifesaving 
treatment with thrombolytic therapy in the emergency room. The 
information is provided to the doctor in ``real time.'' The tool also 
calculates the patient's likelihood of developing serious 
complications, such as hemorrhagic stroke or major bleeding, if given 
thrombolytic therapy.
    A trial to assess whether this instrument, which plugs into an 
existing electrocardiograph machine, will increase the proportion of 
eligible patients receiving recommended treatment is in progress. The 
researchers are also working with the major manufacturer of EKG 
machines to make this tool widely available.
Understanding Variation in Health Care
    AHCPR's research emphasis has been on conditions that are common, 
costly, and for which there is substantial variation in practice. This 
research includes many of the conditions that represent a major 
expenditure for Medicare.
    The issue of variation is not new to you. Dr. John Wennberg's work 
has shown that medical practice varies widely in this country. AHCPR 
has sponsored a substantial portion of Dr. Wennberg's work in the area 
of prostate disease. His research team found that the rate of radical 
prostatectomy for Medicare patients in Clearwater, FL is nearly twice 
the rate in Medina, OH (the national average is 2.0 surgeries per 1000 
Medicare beneficiaries while the rates in Clearwater and Medina are 2.8 
and 1.5 respectively). These variations can vary region to region, 
State to State, or within States. For example, the rate for radical 
prostatectomy for Medicare patients in Baltimore, MD, is approximately 
three times the rate in Salisbury, MD.
    Variation provides us an opportunity to study what care is 
appropriate, how much is enough, and what is fair. This involves 
understanding when variation is due to issues of uncertainty, issues of 
access, and issues of overuse or under use. I would like to note that 
variation isn't inherently bad. The research that AHCPR supports and 
conducts helps us understand whether variation in medical practice 
should be celebrated or eliminated. In some cases, variation is caused 
by geographical, epidemiological, or cultural preferences. For example, 
we expect to have a higher rate of skin cancer in the South, and 
therefore more treatment for skin cancer.
    Outcomes research--which provides the basic knowledge of what works 
and what doesn't work--is the foundation for all efforts to improve the 
quality of health care services. We can use this knowledge to determine 
what the right thing is, when the right time is, and what the right way 
is, and whether we are getting value for what we spend.
Supporting Evidence-based Practice
    A key issue in variation is professional uncertainty. If clinicians 
don't know what works and what doesn't work, they may be inadvertently 
providing inappropriate or ineffective care. AHCPR supports 12 
Evidence-based Practice Centers (EPCs), which provide the scientific 
evidence that others will use to reduce unnecessary variation by 
reducing uncertainty. The 12 Centers develop scientific analyses, known 
as ``evidence reports,'' of the evidence of the effectiveness of a 
particular treatment, technology, or procedure. These analyses are then 
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, the Agency developed an evidence report on the 
findings on colorectal cancer screening. The information contained in 
AHCPR's evidence report led to a clinical practice guideline that was 
developed by the American Gastroenterology Association on colorectal 
cancer, which in turn, contributed to Congress' decision to expand 
Medicare coverage for colorectal cancer screening.
    An important component of AHCPR's Evidence-based Practice 
Initiative is collaboration. The EPC topics are nominated by public and 
private sector organizations which will use and help us disseminate the 
information. The nominators are our partners. For example, the American 
Academy of Pediatrics and the American Psychiatric Association 
nominated attention deficit/hyperactivity disorder as a topic, and they 
have incorporated AHCPR's evidence report into a guideline they 
developed. Similarly, a consortium of patient and provider groups 
nominated management of urinary problems in paralyzed persons as a 
topic, and they will also create a guideline from it. And the Health 
Care Financing Administration asked us to evaluate swallowing problems 
in the elderly to help them determine their coverage policy for this 
area.
Translating Research into Practice
    In addition to providing information on outcomes to clinicians and 
patients, we want to help them use the information to enhance the 
quality of care provided and received. Obviously, developing the 
information isn't enough. We need to make sure that it is available in 
a useful format to anyone who needs it. To achieve that goal, AHCPR, 
the American Association of Health Plans, and the American Medical 
Association worked together to provide one-stop-shopping for best 
practices in clinical care. We developed the National Guideline 
Clearinghouse that makes clinical practice guidelines available to 
every clinician, health system leader, patient, and policymaker who can 
use a computer.
    AHCPR also is looking at the effectiveness of clinical preventive 
services, and the potential they have for saving lives and reducing 
health care costs. The medical literature increasingly recognizes that 
some clinical preventive services provide enormous benefit. We need to 
know which services are most appropriate and effective for which 
patients and when. The Balanced Budget Act expanded Medicare coverage 
for prevention services. The information AHCPR develops will be 
invaluable to you as you deliberate about further expansions in 
coverage for preventive services.
    As a central component of these efforts, AHCPR will support renewed 
activities of the U.S. Preventive Services Task Force. Their 1996 
report provides clinicians with the information on the effectiveness 
and appropriateness of the full range of preventive care--screening 
tests for the early detection of disease, advice to help people change 
their risky health-related behaviors, and immunizations to prevent 
infections. AHCPR will support major new assessments of preventive 
services and updates of priority topics by the Task Force. As requested 
in the Balanced Budget Act, the Task Force will also work with the 
Institute of Medicine to evaluate the implications of including new 
preventive services under Medicare.
    Supporting the U.S. Preventive Services Task Force will continue a 
long and productive partnership between the government and the leading 
primary care medical and nursing organizations. Our activities 
complement the major investment being made by the Centers for Disease 
Control and Prevention (CDC) in the study of preventive services in 
community-based settings. We look forward to working with the CDC on 
integrating our research in this area.
    Finally, I want to thank the Subcommittee for providing the Agency 
with its authority to support Centers for Education and Research 
Therapeutics or CERTS, under the Food and Drug Administration 
Modernization Act. We expect to announce to announce funding for 
several centers before the end of this fiscal year. The CERTS will 
improve the effective use of medical products, such as pharmaceuticals. 
This new authority builds on our existing research in this area. For 
example, clinicians can receive the information they need to help 
reduce the costs of medical care through AHCPR's research on 
pharmaceuticals. With funding from AHCPR, Michael Fine of the 
University of Pittsburgh and colleagues found that using the antibiotic 
erythromycin for treating community-acquired pneumonia in most 
outpatients aged 60 and under significantly reduces treatment costs 
compared with the use of other antibiotics ($5.43 versus $18.51) and 
has no adverse effect on medical outcomes. About 600,000 of the 4 
million Americans who develop community-acquired pneumonia are 
hospitalized each year. This research could lead to significant 
savings.
Improving Decisionmaking in Health Care Systems
    The health care system has gone through some significant changes 
over the past several years. These changes have created new structures, 
processes, and settings in which care is delivered. These changes have 
also raised a number of issues 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 the outcomes of patients who use the 
services. For example, some of the questions we can ask are: What 
happens when patients are discharged quickly from the hospital? How are 
managed care and traditional insurance changing and how are the new 
arrangements affecting access to care and the quality of that care?
    Unfortunately, these changes are happening quickly and we have 
little scientific evidence regarding their impact on the health care 
system, generally, and on quality specifically. AHCPR is conducting and 
supporting research to fill this void.
Providing Research on Market Changes
    I believe that outcomes research is more than measuring the 
outcomes of clinical treatments. Our customers need to understand the 
outcomes of the organizational and financial structures in the way 
medical care is delivered. It isn't enough to know that clinical 
services are safe, effective and appropriate if the structure for 
delivering that care is shaky or untested.
    The journal Health Affairs featured AHCPR's research that presents 
the first comprehensive look at what is currently happening in the 
health care marketplace. The articles form an invaluable evidence-based 
core of information for current discussions of policy options by all 
health care system participants--both public and private.
    These studies, which had a 2-year turnaround from funding to 
report, provide fundamental knowledge about the link between the 
financing and delivery of health care and the quality of services. 
These studies empirically and rigorously examine issues of how current, 
incentive-driven market decisions of multiple participants--hospitals, 
physicians, health plans, employers, employees, and public, private and 
individual purchasers--determine who gets health care, what kind of 
care, how much care, who pays and how much it costs.
Supporting Research To Improve Primary Care Systems
    Issues of systems of care are not strictly limited to hospitals or 
other institutions. We need to understand how patients gain access to 
the system. AHCPR is the only agency that has an expressed 
responsibility to study the structure and delivery of primary care 
services. This research is increasingly important as more care is 
delivered beyond the hospital walls.
    More than half of all Americans are now covered by managed care 
plans, which often require the use of a primary care physician or 
gatekeeper to manage the referral of patients from primary to 
specialists. Access to specialists is a major concern among the public, 
and has been the subject of much debate. To strengthen the scientific 
base underpinning the referral policies of health plans, AHCPR funded 
ten grants on physician referrals, and will be hosting a conference in 
Washington this September where the results will be presented.
Preventing System Errors
    AHCPR-supported research has demonstrated that the processes and 
systems used to provide care are often faulty and can lead to avoidable 
accidents. One conclusion of the research is that many of these 
accidents are not the fault of individuals, and therefore can be 
prevented by evaluating and improving the system.
    In an AHCPR-funded study, Dr. Lucian Leape, a pioneer in research 
on how to reduce errors in medicine, estimated that the number of 
injuries caused by medical errors in hospitals alone could be as high 
as three million annually, resulting in costs as much as $200 billion 
each year. In his work on drug-related errors, Dr. Leape concluded that 
70 percent of these errors are avoidable, and can be prevented by re-
engineering the hospital systems which allowed the errors to occur. 
Other organizations, such as the Department of Veterans Affairs and the 
American Medical Association, are using this research to develop 
programs to reduce preventable errors.
    AHCPR is also examining how changes within systems of care affect 
the delivery of services and their quality. The Health Resources and 
Services Administration (HRSA), the National Institute of Nursing 
Research (NINR), and AHCPR in 1996 convened a joint meeting of experts 
to set a research agenda on the impact of nurse staffing levels on the 
quality of care in hospitals. We will be supporting additional research 
in this area during the current fiscal year.
Developing the Science and Tools to Measure and Improve Quality
    AHCPR is working to refine existing measures and develop new 
measures that accurately reflect the changing health care system. An 
important component in our 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 and population subgroups--particularly 
vulnerable populations such as the chronically ill--and in the full 
spectrum of treatment settings such as rehabilitation and home care.
    The Agency is involved in collaborative projects with private 
sector organizations to develop their own quality measures. For 
example, AHCPR research found that elderly patients who receive beta 
blockers following a heart attack are 43 percent less likely to die in 
the first 2 years following the attack than patients who do not receive 
this drug. That same study found that patients who receive beta 
blockers are rehospitalized for heart ailments 22 percent less often 
than those who do not get beta blockers. However, only 21 percent of 
eligible patients receive beta blocker therapy.
    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 acute myocardial infarction to 
include patients over 75 years of age in the most recent version of the 
Health Plan Employer Data and Information Set (HEDIS 3.0). 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.
    AHCPR's Consumer Assessments of Health Plans (CAHPS) survey 
consists of 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, presented in the CAHPS tested report formats, can help 
consumers and group purchasers compare health plans and make more 
informed choices based on quality.
    The CAHPS materials are designed for use with all types of health 
insurance enrollees (Medicaid and Medicare beneficiaries as well as the 
privately insured) and across the full range of health care delivery 
systems, from fee-for-service to managed care plans. In addition to a 
core set of items designed for use with all respondents, some 
additional questions are targeted for use with certain subgroups such 
as persons with chronic conditions or disabilities, Medicaid and 
Medicare beneficiaries, and families with children.
    We are not suggesting that all providers and plans in every 
clinical setting and every region in this country be evaluated using 
the exact same measures. Measures and instruments should not be one-
size-fits-all, but should reflect the diversity of needs and uses. We 
are advocating a ``department store'' of accepted quality measures, all 
based on science and validated for reliability and usefulness, where 
users of measures can pick the set that fits their need, whether that 
need is to compare health plans or providers, or to conduct a hospital 
quality improvement project.
Supporting Policymakers with Data and Information
    Policymakers need to understand how dramatic growth of managed 
care, changes in private health insurance, and other dynamics of 
today's market-driven health care delivery system have affected, and 
are likely to affect, the outcomes, quality of, cost of, and access to 
the health care that Americans use.
Developing and Improving Information Technology
    Informatics is another important tool for improving the quality of 
health care services. There has been an explosion in the use of 
information technology in medicine, such as telemedicine and 
computerized medical records. These technologies have greater potential 
to improve the quality of, outcomes of, access to, cost of, and use of 
care. To achieve this potential, we need research to determine what 
works and what doesn't work in ``high tech'' health care.
    Informatics is an area of research that is critical to every aspect 
of AHCPR's work . Let me explain. First, the revolution in information 
technology is critical to the ability of health care delivery systems 
to measure and improve the quality of care that they provide their 
patients. They need seamless information systems--linking 
administrative, financial, and clinical data--that can follow patients 
no matter where or from whom they receive care. I am delighted to note 
that much of the pioneering work in developing the prototypes and 
evaluating their usefulness in daily practice was supported by our 
predecessor, the National Center for Health Services Research. AHCPR 
has an important and continuing role to play in evaluating the impact 
of informatics on the cost, access, and quality of clinical care and 
health care systems. Last year we funded eight projects to do just 
that.
    Second, the type of research that AHCPR conducts and supports--to 
assess what works best in clinical practice and how we organize and 
manage the systems in which care is delivered--relies upon information 
technology at every step. The type of rapid analysis and dissemination 
of data on patient outcomes envisioned by some of the quality of care 
proposals under consideration by the Congress will not be possible if 
we do not advance the state of the technology and develop the common 
language that will let systems from various providers, plans, 
purchasers, and payers communicate with one another.
    For both of these reasons, we have recently taken steps to 
integrate our informatics work into our other substantive research 
centers. This step will strengthen our commitment to informatics in the 
long run.
    Because the Secretary believes that health informatics is critical 
issue to the health care system, she asked me shortly after I joined 
the Agency to co-chair the Department-wide Data Council, which has 
become an increasingly important forum for decisionmaking in the area 
of information technology and carrying out the Department's statutory 
responsibilities. AHCPR's experts in informatics will help the Data 
Council as it addresses issues of advancing a common language for 
information technology systems and addressing questions of their 
appropriate use.
    AHCPR's Medical Expenditure Panel Survey (MEPS) provides 
policymakers and others with up-to-date, highly detailed information on 
how Americans as a whole, as well as different segments of the 
population, use and pay for health care. This ongoing survey also looks 
at insurance coverage and other factors related to access to health 
care. MEPS is the only survey that collects expenditure data from the 
non-Medicare population.
    MEPS data is used by Congress and Federal agencies, including HCFA 
and other components of the Department of Health and Human Services, 
Office of Management and Budget, and Department of the Treasury. If 
MEPS data were available during my tenure on the Physician Payment 
Review Commission, it would have been an invaluable source of 
information in helping to make recommendations to Congress on payment 
for physicians.
    These data also are used widely in the private sector by 
researchers at The Heritage Foundation, Lewin-VHI, Urban Institute, 
RAND Corporation, and Project Hope, as well as by health insurance 
companies, pharmaceutical firms, and other health-related businesses.
    Using MEPS data on the first 6 months of 1996, AHCPR researchers 
Philip F. Cooper and Barbara Steinberg Schone have found that as many 
as 6 million Americans choose not to accept health insurance when 
offered it by their employers. The study found that the number of 
workers declining employment-based health insurance increased by 140 
percent between 1987 and 1996 while the number of employers offering 
health insurance increased during those years. Those most likely to 
turn down insurance are young (under age 25), single, Hispanic or 
black, and work for low wages. Possible factors driving this trend 
include the decline in real wages, higher employee contribution rates, 
and State legislation aimed at enhancing insurance coverage which may 
have increased costs.
    AHCPR's assistance is not limited to Federal policymakers. An 
important AHCPR program is the User Liaison Program (ULP), which plays 
a critical role in providing technical assistance to States and local 
policymakers on a wide range of issues. For example, the ULP program 
conducted a workshop geared toward State policymakers to examine the 
latest research findings on the uninsured and what State governments 
have been doing to solve the problem. In 1998, the ULP will provide 
technical assistance to help State legislators and executive branch 
officials plan for and implement the State Children's Health Insurance 
Program (CHIP) recently enacted by Congress.
    One of AHCPR's statutory responsibilities is to conduct assessments 
of new technologies for the Medicare program (HCFA) and the Department 
of Defense. This information is invaluable to Federal policymakers and 
in some case drives coverage policy in the private sector. A case in 
point is AHCPR's technology assessment on lung volume reduction surgery 
(LVRS). This technology assessment concluded that there was 
insufficient evidence upon which to make a scientific judgment 
regarding the effectiveness of LVRS. AHCPR recommended that coverage be 
granted within the scope of a clinical trial, which is now being 
conducted by the National Institutes of Health. AHCPR is supporting the 
cost-effectiveness component of that trial. It is our hope that the 
collaborative efforts between the agencies will yield the information 
needed to make an informed coverage decision on LVRS.
    AHCPR's new Evidence-based Practice Centers will continue to 
produce timely technology assessments that will assist Federal, State, 
and private sector decisionmakers make difficult coverage decisions. 
Private-sector policymakers also use our research to make informed 
health care decisions. Recently, the Pharmaceutical Research and 
Manufacturers of America included AHCPR's research finding on atrial 
fibrillation to promote the use of blood thinning drugs in an 
advertisement touting ``three ways pharmaceuticals are ganging up 
against health care costs.''
    AHCPR's research and data give policymakers the ``big picture'' on 
the cost, use, and access to health care in this country for them to 
use in making decisions about clinical policy, coverage, quality 
improvement, and spending.
Conclusion
    In order for health services research to fulfill its potential to 
improve the quality of the health care system, the foundation on which 
it rests must be strong. This foundation includes the tools that can be 
used to improve health care, the training to nurture and promote the 
best researchers, and the teams that foster partnerships and 
collaborations among the public and private sectors.
    All of these elements will enable AHCPR to meet the challenges we 
face. Mr. Chairman and members of the Subcommittee, I respectfully 
request that you reauthorize AHCPR so that we can help our Nation's 
health care system by:

 Conducting and supporting research on the outcomes and 
        effectiveness of treatments.
 Ensuring that clinicians, patients, health care system 
        leaders, and policymakers have the information that will 
        enhance quality of care.
 Identifying gaps in access to and use of health care services, 
        achieving value for the Nation's health care dollar, and
 Helping the market find ways to fill those gaps.
    These issues are critical to a sound, high quality health care 
system. I look forward to working with the Subcommittee in the months 
ahead to find ways to improve health care decisionmaking.

    Mr. Bilirakis. Thank you very much, Doctor. Doctor, let me 
just go right to the point raised by Mr. Bryant before he left 
on the appropriations. Last year the agency received a 17 
percent increase, and you are seeking an even larger increase 
for the coming year. Why are additional funds necessary, and 
would you do more of the same activities you do now, or would 
you expand the effort into entirely new areas?
    Mr. Eisenberg. When the agency was established in the late 
1980's, the Physician Payment Review Commission offered a 
recommendation to the Congress that some agency like this ought 
to be established, and it said in the report from PPRC to the 
Congress that the budget ought to be hundreds of millions of 
dollars. That was in 1989 dollars. I think ever since then 
people have felt that the agency's budget should be 
substantially higher than it has been.
    In 1995, in fact, we had a cut in our budget. If you were 
to take the budget that we had before 1995 and project it in 
real dollars today, we still have not caught up with that 
budget. So part of our effort is to catch up with where we 
would have been before.
    But more exciting is what could be done with more funding 
that would be available for this kind of research. We are 
funding now a very small fraction of the grants that our study 
sections tell us would help to improve the quality of care and 
access to health care. We believe that there is a lot of 
research that could be done that we are not benefiting from 
because we have not had sufficient dollars to do so.
    But in addition to that, there are some big projects that 
we would like to do. We would like to undertake, for example, 
projects such as those described in this year's budget request 
of getting a better handle on what is happening to the quality 
of care in this country through surveys and through the 
analysis of the data that is currently available, and that will 
cost a substantial amount of money for us to do.
    So the request for the budget increase is in part a 
reflection of the fact that the agency's budget is small. And 
as you said, we had a 17 percent increase in our budget last 
year; but in terms of absolute dollars, that was the smallest 
increase in any agency in the department. So part of this is 
catch up and part is to help fulfill the potential that the 
agency has.
    Mr. Bilirakis. All right. You gave us the example of some 
of the work that you do; and you have mentioned managed care, 
the information made available for better decisions in plan 
selection.
    Let us take an individual family, mom and pop, and they are 
trying to make a decision on managed care, on what kind of plan 
to choose. Now, they would not come to you directly, would 
they?
    Mr. Eisenberg. No, they would not.
    Mr. Bilirakis. They would go to partners with whom you work 
and to whom you furnish information and research?
    Mr. Eisenberg. Well, we provide our partners with the 
capacity to do these measures. We don't go out and collect the 
data. We neither have the funds, nor frankly do we think that 
it is appropriate that we be collecting information on health 
plans, but rather our partners do that.
    They may be a purchaser like a company, Ford Motors, 
General Motors for example are using instruments like this. If 
you are a Medicare recipient, it would be the plan. Or maybe 
your State collects this kind of information. The State of New 
Jersey collected data using the survey that we developed, and 
presented it to all of the people in New Jersey to help them 
make decisions about which plan to join.
    So the individual that you are describing would, depending 
on the way that he or she gets insurance, get the information 
from that organization and compare the different plans that are 
available, if they are lucky enough to have multiple plans 
offered to them. They would compare them on a set of different 
characteristics, including the characteristics of the 
physicians and the hospitals in the plan, as well as the way in 
which the plan meets the needs of its members. The plans would 
be compared in a way that looks familiar because the data are 
arrayed in easily-understood formats, like a lot of other 
consumer surveys where people can compare their options.
    Mr. Bilirakis. Frankly, I am convinced of the good work of 
the agency, but could there be any claims made of duplication 
of effort? In other words--this was created back in 1989. If 
you were not in existence, is any of this being done elsewhere?
    Mr. Eisenberg. Some of it is being done, but most of it 
isn't. Let me be specific.
    The NCQA had a survey that was trying to get at the same 
issues that this survey gets at. Most of the other people using 
this survey did not have anything that they could use. We did 
not want to see duplication, and so we reached out to the 
partners, customers, and asked them what their needs were. We 
worked with NCQA and Medicare to ask them what their needs are 
so each of them now is using the CAHPS survey, but modified to 
their own needs so there is collaboration with the private and 
public sector. So neither Medicare or NCQA had to reinvent the 
wheel. NCQA has an adaptation of CAHPS and Medicare has an 
adaptation of CAHPS.
    For a small plan or purchaser, they do not have the 
resources to adapt the methodology, so they will use it just as 
it was produced.
    Mr. Bilirakis. Thank you, sir. Mr. Brown.
    Mr. Brown. In some of the AHCPR publications, one of your 
research priorities is improving the quality of children's 
health and you look at the--you list eight indicators, low 
birth weight, pediatric asthma, child diabetes. Are you 
considering in your children's health research, are you 
including estrogenic substances and endocrine disrupters and 
what that does to the next generation both in terms of women's 
health and children's health? Is that something that your 
agency is looking at, or should be looking at, in your 
children's research?
    Mr. Eisenberg. We could. I don't recall that that is on the 
list now, but let me explain how we come up with the list and 
then suggest a way in which we could look at that specific 
issue.
    We have a set of evidence-based practice centers which are 
the first step in our developing ways of measuring and 
improving health care. We ask several times a year people like 
clinicians and consumer groups and policymakers what they think 
the most burning issues are and where more data or information 
is needed. Then we have 12 of our evidence-based practice 
centers around the country analyze those particular issues and 
come back with what we call an evidence report, which is a 
synthesis and analysis of data that we then give to that 
partner. The American College of Obstetrics and Gynecologists 
and the American Academy of Pediatrics are two of our partners 
and they come in with a list. I don't recall what was on their 
list. But what we have asked them to do is identify the 
thorniest issues that they need advice on. I can get back to 
you on that.
    Mr. Brown. Because of the public-private partnership that 
you mentioned, you will typically look to organizations like 
that on whether it is on children's issues or minority issues 
or any other kinds of health care issues, you will look to the 
sort of experts in the field and generally accepting their 
advice on directions to take your research?
    Mr. Eisenberg. Exactly. The reason for that is we have a 
commitment to what we are calling ``user-driven research.'' We 
start the way that I described, which is asking where the gaps 
are that we can help to close. But we also believe that if we 
don't start that way and we fund research that does not meet 
anybody's needs, it is going to fill some journals; but it is 
not going to get translated into practice. So we don't just ask 
these people what they want, we also say if we do this work, 
are you going to do something with it. We expect them to say 
yes, in which case we can close the circle of research and make 
it meaningful.
    Mr. Brown. Is the issue of estrogenic substances and 
endocrine disrupters and synthetic chemicals that mimic 
naturally occurring hormones that may cause birth defects and 
some sort of genetic problems 1 and 2 generations later, is 
that more of, possibly, an NIH issue than one for you?
    Mr. Eisenberg. If the question is what its mechanism is, 
what is the biologic mechanism, the physiology or other 
characteristics, yes, it would be much more in keeping with an 
NIH study.
    If the question is to do a clinical trial with 
randomization to see what the effect is in an idealized 
setting, the answer again is yes, that is more an NIH issue.
    If the NIH or others have done research that answers those 
biologic questions and the question is for which patients might 
this be effective and how can we help improve the quality of 
the use of those services, what effect do they have on people's 
functional status, we see it more in our bailiwick. Or how can 
you develop measures of the performance of physicians and 
others in delivering those services.
    Mr. Brown. So the indicators that you discussed in one of 
your fact sheets in HCUP, quality indicators, low birth weight, 
child diabetes, pediatric asthma, if it is possible that you 
could look at that in terms of endocrine disrupters as 
potential causes of some of those indicators?
    Mr. Eisenberg. Yes.
    Mr. Brown. Can you tell me some of the--give me a couple of 
examples of your private-public partnerships that you have 
worked on?
    Mr. Eisenberg. Maybe I can give you two. One is at the 
beginning, and the other is at the end of the research cycle. 
At the beginning of the cycle, we felt that we could use our 
public dollars more effectively if we could use them to 
stimulate some spending on the private side to fund research, 
so we have partnerships with some foundations. For example, we 
are working with the Packard Foundation, AAHP, the Association 
of American Health Plans, the Johnson Foundation, to cofund 
projects that neither alone could do, or because we fund 
different parts of it where our mission is one part and their 
mission might be another part of the agenda. In this way, we 
get projects done that, as I said, probably would not be done 
if either of the two parties could not come to the table. That 
is one way in which we have partnerships.
    Another partnership at the beginning of the cycle reflects 
my response to your previous question which is our agenda 
setting. We are having meetings from the private sector asking 
where should we invest and spend our research dollars on. At 
the back end we also need those partnerships to be sure that it 
gets delivered, so that we can be sure that the product 
actually gets out there. NCQA and the use of the Consumer 
Assessment Health Plan Survey is an example of that one.
    We also have some partnerships with organizations who are 
taking the results of the Put Prevention Into Practice 
products. Some health plans who are taking the template that 
was developed as a public good with public dollars, printing it 
at their own expense, and translating the information so it can 
improve the care of patients who are in those plans and the 
performance of the physicians who are practicing in those 
plans.
    So that is where we have emphasized our partnerships, 
setting our agenda, understanding where the gaps are and 
closing the gaps, to ensure that the research does not just sit 
on a shelf. Those are a couple of examples.
    Mr. Brown. Thank you.
    Mr. Bilirakis. Mrs. Cubin.
    Mrs. Cubin. Thank you, Mr. Chairman. I want to follow up on 
the subject that the chairman brought up last in his 
questioning, but first I need a little information, and bear 
with me because even though I was on this subcommittee last 
year, it is such a huge jurisdiction of medical issues, I don't 
know as much as others do.
    I think you said in the late eighties the Physician Payment 
Review Committee recommended the establishment of AHCPR?
    Mr. Eisenberg. That's right.
    Mrs. Cubin. What did they want you to do at this time? What 
I am getting at is this. Sometimes, and I am not saying--I 
think that your agency does valuable--provides valuable 
services. And where I am going is do we really need a separate 
government agency to provide those services or could they, 
whether in one organization or multiple organizations, be 
provided without having a separate government agency? So that 
is where I am going.
    In the beginning why did the physician payment--what did 
they ask the agency to do?
    Mr. Eisenberg. Well, first, truth in advertising, I was on 
the Physician Payment Review Commission at the time, and I 
remember the discussions well. The argument went like this: if 
we are going to change the way that physicians are paid so we 
have this new payment system and we are trying to get doctors 
to practice on the basis of what works best for the patients, 
rather than how they get paid for those services, then we need 
to be able to be sure that physicians know what works best for 
their patients.
    So there were chapters in the PPRC reports in 1989 and, in 
fact, in preceding years about effectiveness in outcomes of 
medical care. At that time the outcomes agenda and the 
effectiveness agenda was just starting to be identified as a 
major agenda for the research community.
    And so PPRC looked around and said where is this research 
going to come from and concluded that there wasn't a place. 
There was a gaping hole in the research agenda, and it was not 
being done in the private and public sector, and the PPRC said 
some Federal agency is needed to meet this need. Congress then 
created it. And it was their judgment that something was needed 
to provide evidence for practice, to improve quality and 
decrease costs.
    Mrs. Cubin. My concern is that--is the growth of government 
and in the late eighties government was growing exponentially 
with programs and so on. And you know, we are trying, as you do 
know, to define what are the real legitimate functions of the 
Federal Government, State government, and local government in 
as efficient a model as we can.
    And so it seems in a way that AHCPR, instead of need 
driving the agency, the existence of the agency is driving a 
larger need. So it is the growth, I guess, of what is going on 
inside AHCPR that I am questioning because it seems to me that 
between NIH and CDC, AMA, universities, medical schools, it 
seems to me that the information other than what you just said, 
should be there. And so I don't understand why you are the ones 
that are giving grants for research around the country and that 
sort of thing.
    Mr. Eisenberg. I think it is the right question for us to 
ask, and we ask it every day: Where is our value added? If we 
didn't exist, what would not happen so we can focus on those 
areas where we make a contribution and a difference?
    I would love to think that the agency is influential enough 
so we can drive the agenda, but I think the agenda in the areas 
that I described, the desire to contain the increase in health 
care costs, the concern that the country has about health care 
quality, and the concern that the country has about the 
outcomes of care is very external to our agency. Whether we 
exist or not, I think that agenda is going to exist, and I 
think the Nation's concern about those issues will continue.
    Mrs. Cubin. I agree.
    Mr. Eisenberg. I would like to think that if we exist, the 
Nation's concern will be moderated because some of the research 
will help to address those problems. But we ask ourselves and 
our constituency groups all the time whether or not we are 
meeting a need that they have that wouldn't be met otherwise. 
We are small and we need to be sure that our resources are used 
in a way that does not duplicate what other sectors would do.
    I have concluded that those issues about concern about 
outcome, concern about quality and cost would not be adequately 
addressed were the agency not present and that those concerns 
would be on the minds of every American whether we exist or not 
as well. So my conclusion is that we exist in order to solve or 
help to solve those problems that Americans are concerned 
about.
    Mrs. Cubin. Permission just to ask one more question.
    Mr. Bilirakis. Without objection.
    Mrs. Cubin. Thank you. In the reauthorization legislation, 
one of the responsibilities of the agency will be to support 
primary care research and access in underserved areas. Can you 
tell me how you plan to do that. I represent Wyoming, which 
tends to be very underserved in primary care especially.
    Mr. Eisenberg. Yes. We start by asking questions about who 
it is that is relatively underserved and who might have 
insurance but not be able to get access to care. We know that 
having insurance does not automatically translate into access 
to high quality care. Certainly rural America is one of those 
areas that is relatively underserved. We have some reports to 
help us focus and address the needs of rural Americans. We are 
collaborating in several different ways in order to meet those 
needs. We will continue to collaborate with other agencies to 
fund activities in telemedicine to see whether or not the 
impact of telemedicine on quality and outcomes of care is one 
that will help people who live in rural areas. Working on 
issues related to the relationship between different health 
professionals so we can understand what the most appropriate 
deployment of different kinds of health professionals in rural 
areas is another issue that we have dealt with.
    Transportation is a big area for rural America in terms of 
getting its health care. And we have an agenda for research 
related to rural America. There are two problems there. One is 
setting the agenda, and the other is stimulating researchers to 
be interested in those problems because many of the States who 
are most interested in rural issues don't have a substantial 
number of investigators who are capable of doing this kind of 
research and competing successfully for it.
    So that is a second agenda, to be sure that there is a pool 
of talented researchers who are interested in and looking at 
the problems that rural America has. I hope that we can make a 
difference there.
    Mrs. Cubin. Thank you.
    Mr. Bilirakis. To hitchhike on the gentlelady's question, 
you mentioned in response to Mr. Brown that you meet with 
representatives of the private sector to help determine your 
agenda in terms of the areas where they do need some help 
regarding research. How does that take place? Is that done 
periodically? Is that at annual meetings? Who determines who 
these private sector people are?
    Mr. Eisenberg. It goes on in several different ways. One is 
that we respond to people who come to us and say we heard about 
your agency, we would like to talk to you. There was a group 
from Cleveland. They called up and said what do you do. And we 
said, let's talk about what we can do together. All of us spend 
a fair amount of time inviting people to Rockville and meeting 
with them.
    The second is that we have an outreach to organizations 
when they have their annual meetings or executive board 
meetings. I enjoy and am as responsive as I can be to 
invitations to talk to their members and their leadership about 
what we are and listen to them about what we should be.
    Third, we have initiated this year a more proactive 
approach to this, where we have taken sectors of our user 
community and invited in people who are representatives of that 
user community to meet. Two days ago we met in Washington with 
about 15 people from the hospital community, rural hospitals 
and urban hospitals, private and public. The whole range of 
hospitals were represented around the table, and we just said 
what do you need. And then we listened to people for 3 hours. 
We are doing that seriatim with different user groups so we can 
get them together to help us set an agenda.
    Mr. Bilirakis. Thank you. Mr. Green to inquire.
    Mr. Green. Thank you, Mr. Chairman, and I would like to 
first ask unanimous consent to place a statement into the 
record.
    Mr. Bilirakis. Without objection the statement of all 
members of the subcommittee will be made a part of the record.
    Mr. Green. On page 6 one of your funded studies points out 
that where it says: ``Physicians recommended referrals for 
cardiac catherization only 60 percent as often for black 
patients than white patients,'' I want to follow up on my 
colleague from Wyoming's question. Have those results been 
verified by other studies, by the government, public or private 
agencies?
    Mr. Eisenberg. That study was only published about a month 
and a half ago, so there has not been that much time for 
verification. Let me explain what we tried to do with that 
study is to look at what people know happens, which is that 
there are disparities among different groups in the population, 
including racial and gender differences.
    This study was intended to ask why does that happen, not 
just does it happen. So it got into the clinical decisionmaking 
issue and tried to understand the degree to which we as 
physicians are part of institutional racism and gender bias. We 
do need to validate it, and we need other studies to make sure 
that other studies confirm it. We are also looking at what we 
can do to decrease those biases and decrease those disparities.
    Mr. Green. I know that is one of the functions of your 
agency, to look at racial and geographic disparities, and in 
your testimony you talk about the differences in treatment 
geographically based.
    You mentioned at the end of your statement that the 
agency's research should be used as a guide and not as a rule. 
Are you concerned that some of the managed-care providers would 
deny doctors' recommendations based on your research results? 
And what could Congress do to ensure that your research is used 
only as a guide and not as a fixed rule?
    Mr. Eisenberg. I think you should give us clear 
instructions that that is the case. Our research ought to be 
aimed at delivering evidence for decisionmakers so that they 
can make decisions based on the best science that is available. 
The language that the Senate has drafted gives us very clear 
and unequivocal instructions that that is the role of this 
agency, to get the best evidence out there, and that is what we 
intend to do.
    One of the things that you might find interesting is our 
guideline clearinghouse where we have taken the guidelines that 
are developed by public and private sector organizations and 
put them on a website. We have had abstracts written, and this 
is the kind that would never happen if it weren't for a public 
agency who could do it; but you can go in and click your mouse 
to a website to see what the recommendations are that are based 
on evidence--we accept evidence-based guidelines--but what the 
recommendations are of different groups. And you would conclude 
in looking at that that there are multiple ways of taking care 
of patients and that they need to be individualized to the 
individual needs of a patient.
    Mr. Green. On page 20 you are quoting another study of your 
researchers. It is mentioned that 6 million Americans chose not 
to accept health insurance that was offered by their employers. 
Hopefully that was not employer-paid insurance that they 
refused.
    Mr. Eisenberg. Actually it was. That is startling. What it 
told us was just offering people insurance isn't enough. We 
found that the individual said I am not going to get sick; I 
don't want to pay my share of the premium.
    It also happens in Medicare and Medicaid. We have found 
when Medicare offers certain services to individuals, that a 
substantial number of people don't pick them up. With the CHIP 
program, we know that one of the major efforts we need to 
undertake is an outreach program so that the people eligible 
for CHIP will sign up for CHIP.
    I found that piece of research profoundly important in 
changing the way that I think about insurance. We have got to 
get insurance for Americans, but we also need to collaborate 
with those who are offering insurance to be sure that people 
know that they have insurance and that they know the importance 
of getting insurance so that they are covered. In this way, we 
can translate the availability of insurance to the acquisition 
of insurance, and translate that to better quality care.
    Mr. Green. I understand that under 21, particularly single 
and minority, and having a 23-year-old who thinks that he is 
bulletproof I understand, but it just boggles the mind that 
they would not accept insurance.
    Mr. Eisenberg. I have a 21-year-old the same way. You are 
right. It is very difficult to explain to people that they are 
vulnerable and having insurance will help deal with that 
vulnerability. It is not just young people, but it is many 
young people who don't accept the insurance that is offered to 
them.
    Mr. Bilirakis. I thank the gentleman. Dr. Ganske.
    Mr. Ganske. Dr. Eisenberg, how are your research processes 
different from HMOs' guidelines and HMOs' population-based 
studies?
    Mr. Eisenberg. They are quite different. The research that 
we do generates the evidence that people can use to try to 
influence or improve health care. For example, we have these 
evidence-based practice centers that review the literature and 
analyze the available evidence about certain problematic issues 
in health care, and they will come back with a report that we 
then make available. That report might be translated into a 
continuing education program by one professional society, a 
manual by another one, a guideline by another one or by a 
managed-care organization.
    We want to partner with them so they can use the evidence 
most appropriately, but we see ourselves as a partner with 
them. We are not going to write the guidelines. We are going to 
help generate the science-based evidence so that health care is 
based upon good research.
    Mr. Ganske. My point is that your processes require peer 
review?
    Mr. Eisenberg. Yes.
    Mr. Ganske. And they are public?
    Mr. Eisenberg. Yes.
    Mr. Ganske. And they are nonproprietary?
    Mr. Eisenberg. Yes.
    Mr. Ganske. And they are available?
    Mr. Eisenberg. Right.
    Mr. Ganske. Thank you.
    Now, to what extent do your guidelines take into 
consideration individualization for a practitioner treating an 
individual patient?
    Mr. Eisenberg. Let me emphasize that the agency produced 19 
guidelines prior to 1995 and at that time made a decision that 
we should not produce more guidelines, but rather we should 
produce the evidence that helps others develop guidelines if 
they choose to do so. Once they have, we help people gain 
access to them through something like the National Guideline 
Clearinghouse, if they are evidence-based.
    So we really are not producing guidelines any more. So it 
would be hard to answer your question since we are not doing 
the production of guidelines any more, but helping others to be 
sure that their guidelines are based on good evidence.
    Mr. Ganske. But as a physician, you would agree that when 
you are looking at a prevailing standard of medical care, that 
the type of work that you produce is something that should be 
taken into consideration along with peer-reviewed literature, 
NIH consensus statements, and the physician's individual 
examination of that individual patient?
    Mr. Eisenberg. Absolutely on every point. And I would even 
add one, which is to say that we would hope that the evidence 
that is generated by the research that we sponsor about what 
works when and for whom would help to influence what the 
prevailing standard of practice is since none of us wants it to 
be constant.
    Mr. Ganske. And since your work is public and it is peer 
reviewed, there would be nothing that would prevent that from 
being considered as part of a prevailing standard of medical 
care?
    Mr. Eisenberg. That is an essential premise of the way that 
we operate. It is a public good, and it is available to 
everyone.
    Mr. Ganske. I thank you. I thank the chairman.
    Mr. Bilirakis. Mr. Deal?
    Mr. Deal. I don't have any questions. I am learning by 
listening.
    Mr. Bilirakis. Doctor, thank you very much.
    Panel two, if you would come forward. Ms. Mary Woolley, 
president of Research! America based in Alexandria; Mr. Charles 
Kahn, president, Health Insurance Association of America; Dr. 
Charles Mahan, College of Public Health, University of South 
Florida; and Mr. Brian Lindberg, executive director for 
Consumer Coalition for Quality Health Care based here in 
Washington, DC.
    Thank you very much. Thank you for honoring us with your 
presence and complementing the testimony of Dr. Eisenberg. Your 
written statement is already a part of the record and we would 
prefer that you supplement that orally, but obviously the time 
is yours. We are setting the clock at 5 minutes.

   STATEMENTS OF MARY WOOLLEY, PRESIDENT, RESEARCH!AMERICA; 
CHARLES N. KAHN III, PRESIDENT, HEALTH INSURANCE ASSOCIATION OF 
  AMERICA; CHARLES S. MAHAN, DEAN, COLLEGE OF PUBLIC HEALTH, 
 UNIVERSITY OF SOUTH FLORIDA; AND BRIAN W. LINDBERG, EXECUTIVE 
      DIRECTOR, CONSUMER COALITION FOR QUALITY HEALTH CARE

    Ms. Woolley. Thank you, Mr. Chairman.
    Mr. Chairman and members of the subcommittee, my name is 
Mary Woolley; and I am the president of Research!America, which 
is a nonprofit alliance of nearly 400 organizations, 
industries, societies, institutions, and individuals committed 
to making medical and health research a much higher national 
priority.
    Among the things we do are to commission polls to assess 
public attitudes toward research and researchers. Also, we have 
a number of programs designed to help researchers become more 
accountable and more accessible to the citizens who support 
their work. Like the Agency for Health Care Policy and 
Research, Research!America marks its 10th anniversary this year 
and like the AHCPR, Research!America is committed to making 
sure that the full continuum of research can sooner, rather 
than later, deliver on its promise of better health and quality 
of life.
    Without the AHCPR, the public benefits of research, in 
fact, may be needlessly delayed or never fully realized. Just 
last week I testified before the House Labor HHS subcommittee 
reaffirming the public's support of doubling our commitment to 
medical research over 5 years. You can see our survey results 
from the last three rounds of surveying on the chart that is 
displayed. And it shows, among other things, that just in the 
last 9 months or so, public support for doubling our Nation's 
commitment to research has increased from 60 to 68 percent. And 
importantly, the percentage of people who have no opinion has 
been reduced dramatically.
    Now today as I testify before your committee, I bring with 
me evidence of the public support for the work that is 
performed under the auspices of the AHCPR. In our most recent 
public opinion survey, which we will show you now, we asked 
whether citizens value research which seeks to understand why 
there are differences in quality of care and outcomes for 
patients. As you can see here, 92 percent, 9 in every 10 
respondents said that they do indeed value this research. It is 
the AHCPR that champions this value on behalf of the public.
    We also regularly ask what concerns people have about 
research. At or near the top in survey after survey is the need 
for more information. Again, the AHCPR addresses this need. We 
have found that quality information is, in fact, essential as 
we advance research from the bench to the bedside through 
clinical trials. One of the top factors in the public's 
willingness to participate in clinical trials is their concern 
regarding the competence of the institutions and the people 
conducting the research. The AHCPR helps both practitioners and 
institutions evaluate and maintain their own competence and 
disseminates guidelines which help people make informed 
assessments about institutional and practitioner competence.
    The AHCPR's goals are the goals of all Americans concerned 
about health. In just 10 years, the AHCPR has charted, 
explored, and helped us all understand the new landscape of 
quality. It has done so with a very modest commitment of public 
funds, and the agency is one of this Nation's great bargains. 
For the expenditure of just \1/100\ of 1 percent of our 
Nation's health care costs, the AHCPR enhances quality 
measurement, improves outcomes for the elderly and chronically 
ill, strengthens the quality of children's health, expands 
clinical prevention services, furthers education on 
therapeutics, informs consumer decisionmaking, improves access, 
and champions cost savings. Remarkably, considering the limited 
budget of the agency, the AHCPR has had a substantial impact on 
every one of those items.
    By reauthorizing the AHCPR, you will be able to report to 
your constituents that you helped reduce the rates of surgery, 
provided for healthier babies, saved health care costs, and 
improved coverage.
    Your committee support of the AHCPR is greatly appreciated. 
With your continued commitment to the agency, America's 
greatest bargain will be something every authorizer, every 
appropriator, and every Member of Congress can take pride in 
supporting.
    Let me conclude with this thought: as more public dollars 
are spent on research as well as on health care, the public and 
its decisionmakers rightly demand more accountability. By 
helping the practice catch up to the science, as Dr. Eisenberg 
has said, the AHCPR in many ways epitomizes public 
accountability. It is helping us all make smarter, more cost 
effective decisions about health care. Thank you, Mr. Chairman.
    [The prepared statement of Mary Woolley follows:]
     Prepared Statement of Mary Wooley, President, Research!America
    Mr. Chairman and members of the Subcommittee, my name is Mary 
Woolley and I am President of Research!America, a non-profit alliance 
of nearly 400 organizations, industries, societies, institutions and 
individuals committed to making medical and health research a much 
higher national priority. Like the Agency for Health Care Policy and 
Research, Research!America marks its 10-year anniversary this year. And 
like the AHCPR, Research!America is committed to making sure the full 
continuum of research can--sooner rather than later--deliver on its 
promise of better health and quality of life. Without the AHCPR these 
public benefits may be needlessly delayed or never fully realized.
    Just last week I testified before the House Labor/HHS Subcommittee, 
reaffirming the public's support of doubling medical research, and in 
particular the budget of the National Institutes of Health, over five 
years. (Figure 1) Today I testify before your committee with evidence 
of the public's support for re-authorizing the work that is performed 
under the auspices of the AHCPR. The continuum of medical and health 
research extends from basic through clinical research. Health services 
research then closes the gap between what we know and what we do, by 
asking what works, what is most cost-effective, and what is the best 
way to ensure quality in health care delivery. Our nation leads the 
world in the conduct of basic, clinical and health services research; 
we must lead also in assuring that health care delivery is thoroughly 
grounded on our world class research.
    Research!America has been commissioning public opinion surveys 
since 1992, exploring attitudes toward medical and health research, 
researchers, and the agencies, institutions and industries that conduct 
research. We know that the public strongly supports research and is 
willing to pay for it. In our most recent survey we asked whether 
citizens value research which seeks to understand why there are 
differences in quality of care and outcomes for patients. Nine in every 
10 said they perceive value in such research (Figure 2). The AHCPR 
champions this value.
    We also regularly ask what concerns (if any) people have about 
research. At or near the top in survey after survey is the need for 
more information. The AHCPR addresses this need.
    We have also found that quality information is essential when we 
advance research from the bench to the bedside through clinical trials. 
One of the top factors in the public's willingness to participate in 
clinical studies is concern regarding the competence of the 
institutions and people conducting the research. The AHCPR helps 
institutions evaluate and maintain their own competence, and provides 
guidelines which help people make assessments about institutional 
competence.
    In other words, the AHCPR's goals are the goals of all Americans 
concerned about health. In just ten years the AHCPR has charted, 
explored and helped us all understand the new landscape of quality. It 
has done so with a very modest commitment of public funds. Indeed, the 
agency is one of this nation's greatest bargains.
    For the expenditure of just \1/100\ of 1% of our nation's health 
care costs, the AHCPR enhances quality measurement, improves outcomes 
for the elderly and chronically ill, strengthens the quality of 
children's health, expands clinical preventive services, furthers 
education on therapeutics, informs consumer decision-making, improves 
access, and champions cost-savings.
    Remarkably, considering the limited budget of the agency, the AHCPR 
has had a substantial impact on every item I have listed. As this 
nation increases its commitment to NIH and CDC, a multi-fold increase 
for the AHCPR is warranted as well. And it all begins with the re-
authorization decisions this committee will make on behalf of the 
American public. By re-authorizing the AHCPR, you will be able to 
report to your constituents that you helped reduce rates of surgery, 
provided for healthier babies, saved health care costs, and improved 
coverage.
    You and your colleagues are well aware of weekly polls conducted by 
the networks and papers that show health care remains a top public 
concern. Citizens often talk about quality of care, access to delivery 
and the importance of excellence in health care. No one is exempt from 
these concerns--especially when a friend or family member needs care. 
The AHCPR addresses these concerns on our behalf, bringing quality, 
access and excellence to health care in America.
    In summary, I reiterate that the AHCPR is a vital component of the 
medical and health research continuum. In survey after survey, 
Research!America's polls affirm the public's recognition of both the 
economic and health benefits of the full continuum of research, 
including the research conducted under the auspices of the AHCPR. 
Moreover, the public is willing to pay more for research.
    Your committee's support of the AHCPR is greatly appreciated. With 
your continued commitment to the agency, America's greatest bargain 
will be something every authorizer, every appropriator, every 
budgeteer, indeed every member of Congress can take pride in 
supporting. As more public dollars are spent on research as well as on 
health care, the public and its decision-makers rightly demand more 
accountability. The AHCPR in many ways epitomizes public accountability 
by helping us all make smarter, more cost-effective decisions about 
health care--decisions for the individual, for institutions, and for 
all of us, via public policy. As the AHCPR enters a new decade on the 
edge of a new millennium, it enters with both the capability and intent 
to meet public demand for accountability even as it assists the nation 
to deliver on the promise of better health and well-being.
[GRAPHIC] [TIFF OMITTED] T6608.001

[GRAPHIC] [TIFF OMITTED] T6608.002

    Mr. Bilirakis. Thank you. Mr. Kahn.

                STATEMENT OF CHARLES N. KAHN III

    Mr. Kahn. Thank you, Mr. Chairman. I am president of the 
Health Insurance Association of America. I appreciate the 
opportunity to testify today about the AHCPR and the unique 
contribution it makes to improving health care for Americans. I 
have personal involvement in the development of AHCPR as 
minority health counsel to the Ways and Means Committee. I 
helped draft the authorizing legislation establishing AHCPR in 
1989.
    By the 1990's, however, AHCPR became embroiled in 
controversy during the initial budget and appropriations 
process in the 104th Congress. The agency came under fire for 
its role in the Clinton administration's health care reform 
effort.
    Further questions were raised about the AHCPR's involvement 
in the development of medical guidelines. This situation was 
fueled by a particular physician group which felt that it had 
been treated unfairly in the establishment of certain medical 
guidelines. Eventually, congressional concerns were allayed by 
a reorientation of the agency's role in medical guideline 
development and a significant education and outreach effort by 
the agency itself to inform Members of Congress on its 
activities.
    In early 1998, I wrote an article for the policy journal 
Health Affairs which suggested criteria for determining whether 
or not funding of AHCPR should continue. The criteria I 
recommended was, first, does the agency have an agenda that 
cannot be replicated by the private sector; second, does the 
AHCPR provide value added to help policy and medical 
decisionmaking uniquely attributable to its role as an 
independent public agency. I have attached a copy of the 
article to my testimony.
    Today, both as a contributor to the development of the 
agency and as a representative for a major sector of our 
private health care system, I can unequivocally say that the 
AHCPR is meeting these goals. It is fulfilling a purpose that 
no single private company association or foundation can assume. 
Put simply, the agency is making health care in this country 
work better. In my written testimony I have outlined examples 
of distinct AHCPR activities and products that support this 
assertion.
    I want to stress, however, that these are only 
illustrations and only barely scratch the surface. For example, 
since 1994 United Healthcare Center for Health Care Policy and 
Evaluation has used the AHCPR's clinical classification system 
to categorize administrative claims data for research purposes. 
As Dr. Eisenberg pointed out, the Consumer Assessment of Health 
Plans Survey is providing a tool to help Americans decide what 
health plan or insurer best meets their health care needs. It 
is being used by 90 million Americans, the Health Care 
Financing Administration is using it for Medicare and the 
Office of Personnel Management is using it for the FEHB program 
for the Federal employees. With AHCPR's assistance, Aetna U.S. 
Health Care has founded the Academic Medicine and Managed Care 
Forum, which is examining better approaches to collaborations 
on health services research and its dissemination.
    Congress recently reauthorized AHCPR to establish centers 
for the education and research on therapeutics to fund research 
and education on the use of approved drugs, the prevention of 
adverse drug reactions, elimination of pharmaceutical errors 
and the appropriate use of dosage of drugs for special groups.
    As these examples illustrate, the AHCPR plays a significant 
role in helping Americans covered by the private market and by 
public programs such as Medicare. It enables the building of 
evidence of what works and doesn't work in everyday medical 
practice, as well as helping the consumer navigate the health 
care system; and it helps use this evidence to create the 
knowledge to measure and improve the quality of care.
    It is important to point out that AHCPR is neither a 
regulator, a payer, nor a standard-setting body. It is at its 
core an evidence-based science agency that works 
collaboratively with both public and private sectors to develop 
tools and information that they need to improve health care and 
its delivery.
    In my view the agency meets the objectives it has set for 
itself as well as the goals that I offered in my health affairs 
article. HIAA is happy to assist this subcommittee in any way 
as you develop reauthorization legislation for AHCPR. HIAA 
supports the goals of the bipartisan AHCPR reauthorization 
legislation in the Senate.
    In my written testimony I have included comments on that 
legislation that may be helpful to you as you move forward. 
Again, thank you, Mr. Chairman, for the opportunity to share my 
views on the work of the AHCPR. I would be happy to answer any 
questions.
    [The prepared statement of Charles N. Kahn III follows:]
Prepared Statement of Charles N. Kahn III, President, Health Insurance 
                         Association of America
Introduction
    Mr. Chairman, members of the Committee, I am Charles N. Kahn III, 
President of the Health Insurance Association of America. HIAA 
represents 269 member companies providing health, long-term care, 
disability income, and supplemental insurance coverage to over 115 
million Americans. I am pleased to speak to you today about the 
important role that the Agency for Health Care Policy and Research 
(AHCPR) plays in improving health care for millions of Americans.
The Critical Role of AHCPR
    I have a long history of personal involvement with AHCPR. In the 
mid-1980s, when I worked on the staff of Senator David Durenberger, I 
helped the Senator draft one of the early pieces of authorizing 
legislation on health outcomes research; that legislation was a 
precursor to the establishment of AHCPR. Later, I served as Minority 
Counsel to the Ways and Means Health Subcommittee where I worked for 
Bill Gradison, one of the original sponsors of legislation establishing 
AHCPR in 1989. In that role, I contributed to the drafting the agency's 
authorizing legislation.
    While I served as Staff Director to the Ways and Means Subcommittee 
on Health in early 1998, I wrote an article that appeared in Health 
Affairs outlining the role of AHCPR and setting forth criteria for 
assessing its value.
    Through my service on Capitol Hill, I had become keenly aware of 
the agency's promise and the important role it had come to play in 
fostering, undertaking, and implementing health services research. By 
1995, however, AHCPR became embroiled in a series of controversies that 
threatened its existence. During the budget and appropriations process 
in the first session of the 104th Congress, the agency came under 
attack for its involvement in the Clinton administration's 1993-94 
health care reform effort. The House Budget Committee's report on the 
budget resolution for fiscal year 1996 stated: ``The agency is supposed 
to support research and information dissemination on health care 
services and technology, medical effectiveness, and patient outcomes, 
but performed an advocacy role in the health care debate the past 2 
years while its funding increased from $125 million in 1992 to $163 
million in 1994.'' Congressional opposition to AHCPR funding also was 
fomented by complaints by some practitioners, who saw themselves as 
losers under practice guidelines developed by the agency.
    More fundamentally, AHCPR's opponents questioned the need for the 
agency. Critics believed that whatever worthwhile functions the agency 
did perform could be replicated by other government agencies or in the 
private sector.
    Eventually, Congressional concerns were allayed by significant 
education and outreach efforts, as well as a reorientation of the 
agency's role in medical guidelines development. In response to 
Congressional pressure, AHCPR sidestepped conflicts with medical 
specialty groups and other providers by redirecting medical guideline 
activities to the development of methodologies, promotion of guidelines 
use, and synthesis of the literature on treatments rather than actually 
establishing guidelines. In addition, the agency's senior staff and 
health services researchers spent a great deal of time discussing the 
unique role and contributions of the AHCPR with Congress.
    In the Health Affairs article, I outlined two major objectives that 
the agency must meet to continue to fulfill its mission and, thereby, 
justify its existence. First, it must maintain an agenda that meets the 
nation's health policy and research needs in ways that cannot be 
replicated in the private sector. Second, it must continually 
demonstrate added value to health policy making and medical decision 
making uniquely attributable to its role as an independent public 
agency.
    Today, as a representative for one of the most important segments 
of the private health care industry, I can say unequivocally that AHCPR 
is, in fact, meeting these goals. It is fulfilling a purpose that no 
private company, association, or foundation could. The agency plays a 
unique and significant role in helping to make the private health care 
market work. Private markets are driven by informed consumers. As a 
partner with the private market, AHCPR is playing a leading role in 
developing information and measures to help both employers and 
individual health care consumers better understand the value of what 
they are purchasing. And unlike other state and federal government 
agencies, AHCPR is neither a regulator nor a standard-setting body. It 
is, at its core, an evidence-based science agency. It is not a policy-
maker, but informs policy makers in the public and private sector. The 
agency works collaboratively with both the public and private sectors 
to develop tools and information they need.
    In addition to providing tools to help consumers choose health 
plans and providers, AHCPR plays a three-step role in developing and 
disseminating quality improvement measures. First, it builds the 
evidence base for measurement through outcomes and effectiveness 
research. Second, it develops measures and works with other public or 
private researchers to develop measures. Third, and critically 
important, the agency helps disseminate these measures into real-world 
practice.
Examples of Private Sector Collaboration with AHCPR
    The Health Insurance Association of America has first-hand 
knowledge of how the AHCPR can provide valuable information not only on 
health practices but on the financing and delivery of health care. In 
1996 and 1997, AHCPR worked with HIAA to produce Choosing and Using a 
Health Plan, a booklet that explained managed care in clear, concise 
language, and that was made available in English and Spanish. 
Development of the guide required skillful coordination among various 
constituencies in the world of health care. (Consumers, commercial 
insurers, various managed care plans, and providers all ``vetted'' the 
booklet.) This project is exactly the kind of low-cost, consumer-
friendly publishing venture that AHCPR is extremely good at; we were 
proud to be the agency's private sector partner, and a number of our 
companies were happy to distribute the booklet to their policyholders.
    A number of individual health insurance companies who are members 
of HIAA also have worked collaboratively with AHCPR.
    For example, United Healthcare uses the Agency's Clinical 
Classification Software (CCS), which was developed as part of the 
Healthcare Cost and Utilization Project (HCUP), in its plans' medical 
management. United also has worked with Dr. Jose Escarce on two funded 
grants. One studied referrals from primary care to specialists in 
different types of managed care arrangements. The other involves study 
of the quality of care by eye specialists and patient outcomes in 
relation to the features of managed care contracts.
    Since 1994, United Healthcare's Center for Health Care Policy and 
Evaluation has used the AHCPR's clinical classification system to 
categorize administrative claims data for research purposes. The 
International Classification of Diseases (ICD) coding system, the 
health care claims classification system, consists of over 20,000 
codes. The Center has used the AHCPR's clinical classification system 
to aggregate the claims of Medicaid and employer insured members, and 
to compare health status and health services utilization. This 
classification system has been integrated into risk adjustment models, 
and served as a baseline from which to compare other classification 
systems, risk adjustment applications, and episode groups. Ingenix, a 
part of United Health Care's Knowledge and Information business 
segment, provides a software application to United's health plans which 
use the AHCPR clinical classification system to group claims for 
measuring the performance of delivery systems and providers, and to 
profile populations and purchasers.
    The Consumer Assessment of Health Plans (CAHPS), one of the most 
widely used of AHCPR's 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. According to AHCPR, it is being used 
by 20 States, 10 employer groups, a wide range of health plans, and at 
least one large employer. The Health Care Financing Administration 
(HCFA) has also used CAHPS to survey Medicare enrollees in managed care 
plans to assess their experiences. The Office of Personnel Management 
will use CAHPS to report consumer assessments of their health plans to 
federal employees.
    With AHCPR's assistance, Aetna U.S. Healthcare has founded the 
Academic Medicine and Managed Care Forum, which is examining better 
approaches to collaborate on funding and dissemination of research. 
Aetna also has adopted guidelines developed by AHCPR for the treatment 
of low back pain in both its disease management program and its 
continuing medical education monograph for practitioners. In addition, 
Aetna uses AHCPR's evidence-based guidelines (e.g., cataract surgery) 
to help establish clinical policy.
    AHCPR also was instrumental in developing the National Guideline 
Clearinghouse (NGC) in collaboration with the American Medical 
Association and the American Association of Health Plans. The NCG, 
which went live on the Internet on December 15, 1998, will serve as a 
comprehensive resource on evidence-based clinical practice guidelines. 
To date, it contains over 500 clinical practice guidelines submitted by 
over 67 guideline developers.
    AHCPR has taken significant steps to close the gap between what we 
know about appropriate treatments 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. It is also being used by a number of health 
plans in the private sector to improve outcomes for patients with heart 
failure.
    One new role that the agency has been asked to take on by Congress 
highlights this. The Food and Drug Modernization Act of 1997 
established 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. For example, research has shown that 
the over prescribing of antibiotics can lead to resistance to an 
antibiotics therapeutic effects. Given the growing importance of 
pharmaceutical treatments, and their growing costs, information 
developed through this AHCPR project will be critical to helping HIAA's 
members ensure that patients receive appropriate medications at a 
reasonable cost.
    Clearly, without the type of support from AHCPR outlined above, 
private health plans alone would have too few resources and too little 
capacity to produce these types of measures and evidence.
Analysis of AHCPR Reform Legislation
    There have been several bills introduced and considered during the 
106th Congress that would reform some aspects of AHCPR. Before 
concluding, I would like to briefly share HIAA's views on that 
legislation.
    Earlier this year, Senator Frist introduced bipartisan legislation 
(S. 580) to reauthorize AHCPR. The legislation currently has 11 
cosponsors, including Senator Jeffords (R-VT), Senator Kennedy (D-MA), 
Senator Mack (R-FL), and Senator Mikulski (D-MD). On March 17 and 18, 
the Senate Health Education Labor and Pension Committee marked up 
Patients' Bill of Rights Act legislation (S. 326) that contains a 
slightly modified version of S. 580.
    Generally, HIAA supports the goals embodied in the Senate 
legislation. S. 580 would make a number of important modifications to 
AHCPR's statutory authority, clarifying its role as an evidence-based 
science agency and ensuring that it would continue to be a strong 
partner in improving the nation's health care system into the next 
century. For example, the legislation would expand the priority 
populations listed in the existing statute to encourage AHCPR to focus 
efforts on children and people with special health care needs, such as 
those with disabilities and those who need chronic care.
    In addition, the bill expressly prohibits the agency from mandating 
``national standards of clinical practice or quality healthcare 
standards.'' This would reinforce that the agency has no regulatory 
authority and that its role should be limited, appropriately, to 
building the science of quality and letting private and public sector 
purchasers actually set quality standards. The legislation also 
includes several measures to ensure that promising research findings 
are translated more rapidly into improvements in daily practice by 
promoting the use of Healthcare Improvement Research Centers, Provider-
based Research Networks, and similar innovative mechanisms.
    To better help consumers measure, compare, and understand the 
health care options available to them, the legislation would require 
the agency to expand current data measurement activities and to report 
annually on national trends in quality. This report would be comparable 
to the ``leading economic indicators'' that now inform us about the 
health of our economy. Importantly, the legislation also would require 
the AHCPR to consider differences between types of health plans, 
delivery systems, and provider arrangements in developing data 
collection measures. As you know, Mr. Chairman, data collection and 
reporting standards that may be appropriate in an HMO setting are not 
always appropriate for PPOs or other types of delivery systems, and 
vice-versa.
Conclusion
    Patients and health care practitioners need the best scientific 
evidence so they can make informed choices about treatment 
alternatives. Health plans, purchasers, and policymakers need to know 
the latest evidence on the most effective ways to organize, finance, 
and manage the delivery of health care. The pharmaceutical, 
biotechnology, disease management, and equipment and device industries 
need to know how to best focus their research investments and design 
new products. And we all need to know how to recognize and choose high 
quality health plans and practitioners.
    As I have outlined above, AHCPR plays a significant role in helping 
the private market, and public programs (such as Medicare) that rely on 
private health plans in two basic ways: it builds the evidence of what 
works and doesn't work in everyday practice; and it helps use this 
evidence to create the knowledge to measure and improve the quality of 
care.
    I strongly believe that the agency continues to meet the objectives 
it has set for itself and the goals I outlined in my Health Affairs 
article last year. I would be happy to answer any questions you may 
have at this time.

    Mr. Bilirakis. Thank you, very much, Chip.
    Dr. Mahan.

                 STATEMENT OF CHARLES S. MAHAN

    Mr. Mahan. Thank you, Mr. Chairman. I am Dr. Charles Mahan. 
I am an obstetrician and dean of the College of Public Health 
at the University of South Florida in Tampa.
    I strongly support the reauthorization of AHCPR, and I 
would like to introduce two recent articles just from the last 
few weeks into my testimony.
    Mr. Bilirakis. Without objection, those will be made a part 
of the record.
    [The articles are retained in subcommittee files.]
    Mr. Mahan. These show the importance of customer service on 
our ability to meet our Nation's health care goals. One is from 
Massachusetts showing 40 percent of the women who have babies 
that died stopped going for health care because of 
communication problems with their doctors; and another from 
Yale showing that our colleagues there have done some neat 
things for homeless veterans to figure out how to get them into 
health care by co-locating services.
    I have been practicing in health care for 35 years, and my 
main area of practice has been trying to get better access for 
women into the health care system. Fifteen years ago, Florida 
started getting concerned about its infant mortality. We were 
last in the Nation, and one of the big parts of that is that we 
were last in the Nation in getting women into care.
    We did the usual things for 5 years. We expanded the 
Medicaid program, hired more doctors and nurses at the health 
departments, and we were still last even though we were making 
slight improvements in infant mortality. At that time we did an 
extensive effort in all of our delivery hospitals around the 
State to interview women who had no prenatal care, expecting to 
find problems with these women.
    To our chagrin the women on the average each had tried five 
times to get into care, and the enemy was us. Then I went for a 
week at the Walt Disney Company to their customer service 
program. I was one of the first health care people to ever go 
to that program. The other folks there were from General Motors 
and Kodak and IBM, and we incorporated Disney's customer 
service program into our State public health program along with 
quality improvement programs, key outcome indicators, and 
goals. And we saw some amazing turnarounds in the way we 
provided care, and now Florida is in the top third of all 
States in getting women into health care.
    We certainly need to focus through AHCPR on national 
research and evaluation of why people are not using our health 
insurance programs in an appropriate manner. You can forget 
outreach, we found. You do not need to go door to door to get 
people into care. If you improve services, both prevention and 
curative services, you build it that way, and they will come. 
And we have seen places that had 10 to 12 percent of women not 
getting care shrink away to less than 1 percent within 6 months 
after the word got around in the community that that place was 
okay.
    Dr. Eisenberg's definition of quality of care in his 
written testimony includes the words ``in the right way for the 
right person.'' In the right way is a very important thing. 
Each person and each community has a different definition of 
what quality service is in health care, and it is heavily 
weighted by their perception of the kind of treatment that they 
got. Kind and considerate service is one of the most important 
parts of the attainment of good health, and that is what we are 
working on with the handouts and in cooperation with the Walt 
Disney Company and the National Perinatal Association. Thank 
you.
    [The prepared statement of Charles S. Mahan follows:]
Prepared Statement of Charles S. Mahan, Dean, College of Public Health, 
                      University of South Florida
    Over the past 15 years, Florida has made the most rapid 
improvements in infant mortality and child health of any large state.
    The most important step we took was to improve the accessibility by 
women and children to our caregivers. We were the worst in the nation 
in the number of women not receiving prenatal care. Since most of us 
blamed the women themselves for that, we decided to confirm our 
suspicions by extensive interviews of postpartum women who had no 
prenatal care. To our surprise and horror, we found that the enemy was 
us. The average woman had tried five times to access health services 
and had found enormous barriers to doing so. Barriers such as:

 five stops to determine eligibility, often with no
 transportation available;
 six hour waits at the clinics;
 unfriendly clerks and providers;
 unavailability of appointments;
 lack of translators, etc.
    Why is getting people into care important? Wouldn't we save a lot 
of money if people just didn't use prenatal care or well-child care 
services unless they were very ill? The answer is no--we save an 
enormous amount of money if women and children use preventive services. 
We save $3.00 for every dollar spent on prenatal care; we save $11.00 
for every dollar spent on childhood immunizations and we save $16.00 
for every dollar spent to help people space their pregnancies and more 
if they previously had a low birthweight baby. So it is in America's 
best interest to make access to health services as easy and welcoming 
as possible. It's just good common sense and good business. The health 
industry, the largest industry in the U.S., is the last industry to 
begin to wake up to the idea that excellence in customer service is key 
to improving our health outcomes.
    Successful interventions: Using modern prevention marketing 
techniques (personal interviews, focus groups, etc.) and training 
precepts from Disney's famous customer service program, we instituted a 
state-wide ``Golden Rule'' program for public health providers. ``Our 
health department services should be so friendly and so good that any 
of us would select them as provider of first choice for ourselves and 
our families.'' Key outcome measurements were tagged to the Goals for 
the Year 2000 and all counties were compared in their progress toward 
those goals. Shining examples of success were Lee County (Ft. Myers) 
where the ``no prenatal care'' rate went from 10% to less than 1% in 
one year with the establishment of teams of nurse-midwives. Another has 
been Seminole County (near Orlando) where services are the best I've 
seen anywhere, public or private--15 minute waits, maximum; all 
problems cared for at the same visit; and cheery, welcoming people and 
surroundings. While there are stellar examples of customer service by 
health care organizations--Moffitt Cancer Center and All Children's 
Hospital in Florida and The Mayo Clinic in Minnesota--those are, sadly, 
not the industry norm. My argument is, if public health departments can 
bring their customer service quality up to that of the Mayo Clinic, 
considering the vast differences in funding, anybody can!
    Our college and The Chiles Center are joining with the Walt Disney 
Company, the National Perinatal Association, The National Public Health 
Leadership Development Network, the Department of Health and Human 
Services and private foundations and corporations to begin a national 
twenty year endeavor to improve access, quality and satisfaction in the 
U.S. health industry including public health. The program ``Friendly 
Access'' is outlined in your attachments.
    We strongly believe that this approach will remove the many 
existing impediments to care for mothers and children of all walks of 
life and result in the establishment of a real system of care for this 
group--something this country has never had.
    There is strong evidence that this approach works but, above all, 
it is the right thing to do. Thank you.

    Mr. Bilirakis. Thank you very much. Mr. Lindberg.

                 STATEMENT OF BRIAN W. LINDBERG

    Mr. Lindberg. Good morning, Chairman Bilirakis and ranking 
minority member Brown and others on the panel.
    The Coalition is a national membership organization of 
consumer groups committed to the goal of assuring and improving 
quality of health care for all Americans. Our work is guided by 
the empowerment principles of consumer rights, protections, 
choices, information assistance and self-responsibility and by 
the strong belief that our Nation must make the necessary 
investments in the evaluative infrastructure that can measure 
the impact of our health care delivery system on quality and 
the health status of Americans.
    With these core principles and beliefs as our compass, the 
coalition is delighted to comment on the reauthorization of the 
Agency for Health Care Policy and Research. Over a quarter 
century ago, Dr. John Wennberg began his pioneering work 
documenting the variation in medical practice. Dr. Wennberg 
attributed variation to a high degree of medical uncertainty 
and the absence of clear scientific evidence demonstrating 
benefits to patients of various treatment interventions.
    Not enough has changed in the intervening years. We know 
shockingly little about the effectiveness of the services we 
are paying for. The challenge ahead is to build the science of 
evidence-based medicine through a commitment to outcomes 
research.
    Mr. Chairman, this is not our only challenge ahead. The 
diffusion in integration of new knowledge to the actual 
practice of medicine is an equally complex task. Mr. Chairman, 
where is the health care consumer in this equation? At present, 
most consumers have very little understanding of practice 
variation and how medical uncertainty can compromise effective 
medical decisionmaking.
    Consumers generally assume good technical care and the 
clinical competence of physicians. But consumers need to be 
exposed to unbiased information about their medical care 
options and the potential outcomes for each option that are 
most relevant to them, including functional status, well being 
and quality of life. This information and this new dialog with 
health care consumers will promote a concept long advocated by 
Dr. Wennberg, the concept of shared decisionmaking between 
consumer and clinician.
    Regarding the reauthorization of AHCPR, Mr. Chairman, today 
I want to request that this committee send a strong signal of 
your commitment to providing objective science-based 
information to patients and clinicians by supporting 
reauthorization of AHCPR. The consumer coalition supports AHCPR 
as an independent, unbiased nonregulatory Federal agency 
committed to building the science of evidence-based medicine.
    Under the leadership of Dr. John Eisenberg, AHCPR has moved 
forward in the rapidly evolving health care environment and has 
staked out critical, broadly supported roles in the areas of 
outcomes, research, technology assessment, quality measurement, 
and quality improvement activities.
    Consumers benefit directly from information created by 
AHCPR on the risks and benefits of various treatment options to 
support their health care decisionmaking. The availability of 
this information reinforces the central role of consumers in 
directing their own health care.
    Consumers also benefit indirectly from the research that 
AHCPR does to assist physicians and other health care providers 
in doing a better job of providing appropriate and high-quality 
care. AHCPR's roles in conducting health services research, 
disseminating that research and the findings and evaluating the 
use of the research in influencing practice behavior has a 
significant impact on improving the quality of patient care.
    I also commend AHCPR on its new focus or research 
priorities for the coming year. AHCPR has proposed to fund 
research in several areas about which the coalition cares 
deeply. We believe that one of the critical measures of any 
health care system is how well it serves the chronically ill 
and the elderly. AHCPR will study how various system 
characteristics affect health outcomes, access and quality of 
care provided to these vulnerable populations.
    In conclusion, I want to briefly address the issue of 
funding AHCPR. I believe that we need to pay closer attention 
to the direct and often immediate return on the investment that 
is made with funds provided to AHCPR. Their budget is simply 
not large enough to do all that could and should be done to 
improve the practice of medicine, improve the outcomes of 
treatment for patients and inform practitioners and patients of 
the effectiveness of their options.
    Thank you again for including the coalition and our 
viewpoints in the hearing today, and I would be happy to answer 
any questions that you have.
    [The prepared statement of Brian W. Lindberg follows:]
  Prepared Statement of Brian Lindberg, Executive Director, Consumer 
                   Coalition for Quality Health Care
Introduction
    Good morning, Chairman Bilirakis, ranking minority member 
Representative Brown, and other members of the Subcommittee on Health 
and Environment of the House Committee on Commerce. My name is Brian 
Lindberg and I am Executive Director of the Consumer Coalition for 
Quality Health Care. The Coalition is a national membership 
organization of consumer groups committed to the goal of assuring and 
improving the quality of health care for all Americans. The Coalition 
is an active forum for consumer groups to come together to develop 
policy positions on issues related to consumer protection, quality 
assurance and informed consumer choice in the health care field. Our 
work is guided by the empowerment principles of consumer rights, 
protections, choices, information, assistance and self-responsibility 
and by the strong belief that our nation must make the necessary 
investments in an evaluative infrastructure that can measure the impact 
of our health care delivery system on quality and the health status of 
all Americans. With these core principles and beliefs as our compass, 
the Coalition is delighted to comment on the reauthorization of the 
Agency for Health Care Policy and Research (AHCPR).
The Challenge of Medical Uncertainty
    Over a quarter of a century ago, Dr. John Wennberg began his 
pioneering work documenting wide variation in medical practice. Dr. 
Wennberg attributed variation to a high degree of medical uncertainty 
and the absence of clear scientific evidence demonstrating the benefits 
to patients of various treatment interventions.
    Little has changed in the intervening years. Medical care is 
America's largest industry, consuming over a trillion dollars annually, 
yet we know shockingly little about effectiveness of the services we 
are paying for. The health care system continues to pay for what has 
always been done and for new medical procedures and treatments without 
clear scientific evidence of the benefits for patients. The challenge 
ahead is to build the science of evidence-based medicine through a 
commitment to outcomes research. Evidence-based medicine will lead to 
an investment in health care services having a measurable probability, 
rather than an untested possibility, of improving health status.
    Mr. Chairman, this is not our only challenge ahead. Even if we are 
successful in developing the science of evidence-based medicine, the 
diffusion and integration of new knowledge into the actual practice of 
medicine is an equally complex task. It is difficult for providers, 
much less consumers, to keep up with the ever-changing knowledge base 
as medical research produces new understanding of health, illness, 
treatment, and outcomes. For example, recent and clear scientific 
evidence that the administration of beta blockers after a heart attack 
will reduce mortality risk and reoccurrence rates has not significantly 
changed the practice patterns of clinicians and low beta blocker use 
rates. Building the science of information transfer, quality 
improvement, and cognitive learning, while aligning economic incentives 
to encourage best practices, must become a necessary complement to our 
investment in outcomes research.
    Mr. Chairman, where is the health care consumer in this equation? 
At present, most consumers have very little understanding of practice 
variation and how medical uncertainty can compromise effective medical 
decision-making. Consumers assume good technical care and the clinical 
competence of physicians. More often than not, they defer decision-
making authority about their own health and medical treatment to 
physicians who ``Know best.'' Indeed, public opinion surveys suggest 
that consumers do not even define quality of care in the context of 
appropriate diagnosis, treatment and achievement of the best outcomes. 
Good quality care to consumers means convenient access to care, choice 
of provider, health professional interpersonal skills (``bedside 
manner'') and low out-of-pocket expenses.
    Mr. Chairman, it is time to expose consumers to medicine's hidden 
secrets: medical uncertainty, practice variation, and the limitations 
of medicine. Medicine is not an exact science. Quality of care is not 
all the same. Clinical performance of plans, providers, physicians is 
highly variable. Perfect outcomes cannot be guaranteed. There is a 
range of treatment modalities for diagnosed illnesses. Most 
importantly, consumers need to be exposed to unbiased information about 
their medical care options and the potential outcomes for each option 
that are most relevant to them, including functional status, well-
being, and quality of life. This information and this new dialogue with 
health care consumers will promote a concept long advocated by Dr. 
Wennberg--the concept of shared decision-making between consumer and 
clinician.
Reauthorization of AHCPR
    Mr. Chairman, today I want to request that this Committee send a 
strong signal of your commitment to providing objective science-based 
information to patients and clinicians by supporting reauthorization of 
AHCPR. The Consumer Coalition Supports AHCPR as an independent, 
unbiased, non-regulatory federal agency committed to building the 
science of evidence-based medicine. Under the leadership of Dr. John 
Eisenberg, AHCPR has moved forward in the rapidly evolving health care 
environment and has staked out critical, broadly supported roles in the 
areas of outcomes research, technology assessment, quality measurement, 
and quality improvement activities. Consumers and patients benefit 
directly and indirectly from the work of AHCPR. We are, in the long 
run, AHCPR's most important customer.
    First, consumers benefit directly from information created by AHCPR 
on the risks and benefits of various treatment options to support their 
health care decision-making. The availability of this information 
reinforces the central role of consumers in directing their own health 
care. Another direct impact that AHCPR has had on consumers is its 
collaborative work on the Consumer Assessments of Health Plans Survey 
(CAHPS) which has led to a widely accepted tool to provide consumers 
and others feedback from the patients themselves. An assessment tool 
like this is one of the necessary elements in the consumer information 
package that will eventually be available and enable more meaningful 
decision-making.
    Consumers will also reap the rewards of AHCPR in the area of 
preventive services. With new assessments of preventive services, 
consumers will get more appropriate treatments, and may even find more 
preventive services covered in the future as a result of AHCPR 
research.
    Second, consumers benefit indirectly from the research that AHCPR 
does to assist physicians and other health care providers in doing a 
better job of providing appropriate and high quality of care. AHCPR's 
roles in conducting health services research, disseminating research 
findings, and evaluating the use of this research in influencing 
practice behavior has a significant impact on improving the quality of 
patient care.
    For example, the 12 Evidence-based Practice Centers that AHCPR 
supports provides an appropriate role for the federal government in 
outcomes research. This research creates the information base necessary 
to develop practice guidelines and quality improvement protocols. AHCPR 
looks to those who are interested in developing guidelines and assists 
their efforts with objective, scientific evaluation of the studies that 
have been conducted in terms of their design and validity.
    As a result, the patients of the future are ensured that good 
science has been used in the development of practice guidelines. Good 
guidelines ultimately lead to good care for more patients. The National 
Guideline Clearinghouse is a logical and much needed approach to making 
clinical practice guidelines available to all those health care 
providers, clinicians, and consumers that could benefit from their use.
    AHCPR is not in the business of duplicating the work that the 
private sector has the ability and resources to do. In fact, AHCPR 
looks to find opportunities to supplement, build upon, and fill gaps 
with their research, often providing the only available resources for a 
particular study.
    The Consumer Coalition is particularly interested in and supports 
the role of AHCPR in researching the impact of managed care on quality. 
The Coalition was created in 1993 in response to the health reform 
efforts that could have moved millions of Americans into managed care 
delivery systems. That potential led us to develop views on what kinds 
of information consumers need in such systems and how health care 
delivery should be evaluated. We did not and do not oppose managed 
care. We believe that AHCPR is in an ideal position to improve the 
public debate about heath care delivery systems and their advantages 
and disadvantages by researching the areas of practice that are most 
likely to produce risks and benefits to consumers. This research must 
be broadly based and lead to a better understanding of how delivery 
systems could be modified to best serve the consumer.
AHCPR's Fiscal Year 2000 Proposals
    I would like to make a few brief comments on the ambitious and 
admirable plans that AHCPR has for the next fiscal year. To begin, I 
commend AHCPR for its focus on new research priorities. AHCPR has 
proposed to fund research in several areas about which the Coalition 
cares deeply. We believe that one of the critical measures of any heath 
care system is how well it serves the chronically ill and the elderly. 
AHCPR will study how various system characteristics affect the health 
outcomes, access, and quality of care provided to these vulnerable 
populations.
    Children are also a focal point of AHCPR's research effort in the 
future, including a study of the effectiveness of certain diagnostic 
and preventive interventions for children with chronic illnesses and 
disabilities. Research on women health, domestic violence, and 
improving outcomes for minorities are also priorities for 2000 and we 
commend these choices.
    Another identified priority for AHCPR is the creation and 
improvement of databases and tools to be used in monitoring health care 
systems and decision-making. For example, the Coalition supports the 
development of an early warning system to measure and track changes in 
quality, access, and cost. This will enable AHCPR to develop reports on 
the quality of care that consumers receive in terms of clinical 
quality, access, and patient satisfaction.
    Emergency care has been a hotly debated issue of late, and AHCPR 
will be able to track the impact of managed care policies on access to 
emergency care services. More objective information will influence the 
public policy discussions and inform consumers and providers of the 
practice patterns that exist. AHCPR will also track Medicaid 
beneficiaries' use of primary care services and their relationship to 
hospital stays. Research findings may indicate that increased use of 
primary care improves quality and saves dollars. We also support the 
use of research grants to develop and test quality measures and CAHPS 
in nursing homes and other facilities.
Conclusion
     In conclusion, I want to address the issue of funding AHCPR. I 
understand that AHCPR has a budget that is approximately one percent of 
the budget of the National Institutes of Health (NIH). NIH does 
important work and I would not argue to reduce their funding. However, 
I believe that we need to pay closer attention to the direct and often 
immediate return on the investment that is made with funds provided to 
AHCPR. Their budget is simply not large enough to do all that could and 
should be done to improve the practice of medicine, improve the 
outcomes of treatment for patients, and inform practitioners and 
patients of the effectiveness of their care options.
    Again, I want to thank you for the opportunity to testify before 
this distinguished Committee. The Consumer Coalition believes that 
AHCPR plays an integral role in the health care system that would not 
otherwise be fulfilled. Their independent, objective, and scientific 
approach to quality research has served both consumers and clinicians 
well. AHCPR's commitment to partnerships with stakeholders in the 
health care system and the fact that their products serve such a broad 
range of practitioners and health care organizations makes them an 
invaluable player in this field.
    Thank you and I would be pleased to answer any questions that you 
may have.

    Mr. Bilirakis. Thank you very much, Mr. Lindberg.
    Let me go to Dr. Mahan. The advancements that Florida has 
made that you referred to in providing access to prenatal care 
for mothers is impressive, and I was very interested to hear 
your comment about ``build them right and they will come.''
    I know back in the days when our late Governor Chiles was 
up here in the Senate, I worked with him very closely on infant 
mortality because the statistics were just horrible, not just 
for Florida but for the entire United States. We came to the 
conclusion at that time that the resources were there, but we 
just had to find a way to get the mothers to the resources. We 
even talked about mobile facilities to go into the 
neighborhoods. So I am very pleased to hear you make that 
comment. But how would reauthorization of AHCPR help the 
University of South Florida?
    Mr. Mahan. Well, I think it would help us focus on the--
obviously we are pretty far along in our partnership with the 
Disney folks, and this is after 20 years of experimenting on my 
part in Minneapolis and North Florida and finding that it works 
very well to do it. But as health care providers, we are all 
pretty sure that we are doing the right thing, and it takes 
modern methods of prevention, marketing, focus groups, to go 
out into the community and talk to people that are not 
receiving care, and those are middle income and lower income 
people, to go back and convince practitioners in that community 
that we need to do a lot more to reach out to them.
    Mr. Bilirakis. Doctor, I believe we are going to 
reauthorize the agency, but if it were not reauthorized, would 
that hurt your efforts?
    Mr. Mahan. I think so. We have worked with Dr. Simpson from 
the agency for years. She has been down to the college. We have 
talked about improvements in access issues, and it certainly 
would--we would hope that they would be our partners in this 
effort nationally, which we consider to be a 10- to 20-year 
national program, finding what works and getting people to use 
the health insurance that we are offering.
    Mr. Bilirakis. So you consider them an integral part of 
what you are trying to do?
    Mr. Mahan. Absolutely.
    Mr. Bilirakis. Let me throw this out without requiring an 
answer at this point. We are governed up here by CBO. A piece 
of legislation like this, they score it. And of course they 
always take into consideration the money going out and never 
really take into consideration the money that might come in.
    So I would ask you to furnish in writing to us how you 
determine the savings. We know that there are going to be 
savings over the long haul, but how do you determine the 
savings achieved from services that your center provides, the 
pregnancy counseling, et cetera? If you can do that, that can 
be an awful lot of help to us in scoring, which is tough to try 
to overcome.
    Mr. Mahan. Absolutely. With mothers and children, it is 
easy to measure those savings.
    Mr. Bilirakis. It would be great to get that information.
    Mr. Kahn, you expressed in your testimony the difficulty an 
agency like this can run into if it delves into health policy 
and gets into the business of standard setting. Is there 
anything more that we as a Congress should do to help to shield 
the agency from such criticism in the future? We are talking 
about reauthorizing legislation.
    Mr. Kahn. I think the agency has done yeoman's work in 
terms of fine-tuning its mission, and I think the 
reauthorization language on the Senate side or comparable 
reauthorization language is--would set it on the right path for 
the future.
    I guess I would like to stress two points: one, the work in 
health policy up here can really not be done without the 
medical expenditure survey work that is done by AHCPR. No one 
else has that data.
    Mr. Bilirakis. No one else private or public?
    Mr. Kahn. That is correct. And the budget office could not 
do some of the estimates without that data. So that is a 
critical role.
    Second, I believe that--and it is easy for me to say, but I 
believe the agency ought to get the higher authorization level, 
and as high an authorization level as you can see your way 
clear to because basically they now have a queue, and that 
queue has in it possible benefits to patients and conditions 
that can be reviewed and studied and health systems questions 
regarding the uninsured and others, and that queue is pretty 
full and it almost is down to--and I think they do a careful 
job of triaging that queue--it comes down to dollars. And the 
more dollars they have, the more conditions they can look at 
and the more critical questions they can ask in terms of health 
systems delivery.
    So I guess what I would ask you to do is to search through 
your set of priorities and see how far you can go. But I think 
a healthy reauthorization level for a number of years is very 
important.
    Mr. Bilirakis. Thank you so much. Mr. Brown.
    Mr. Brown. Thank you, Mr. Chairman. Mr. Lindberg, I had 
asked Mr. Eisenberg about endocrine disrupters and estrogenic 
substances. Sort of playing off the question and his very good 
answer, how do we encourage and stimulate more research and 
physician education and patient knowledge about the whole issue 
of synthetic chemicals and mimicking hormones and what that 
does to the next generation or two?
    When you look back at our society 50 years when we looked 
at toxic chemicals, we figured if they did not kill somebody or 
cause illness right away that they were more or less safe, and 
then we studied chemicals for cancer; and that is what we have 
done over the last 2 or 3 or 4 decades. And only now people are 
beginning to understand more both in laboratory studies and in 
animal studies, and with human beings, what they might do in 
the future.
    Where does that fit in for government research? He 
mentioned NIH, and we both mentioned NIH and also AHCPR. How 
does that fit in for you in your mind?
    Mr. Lindberg. First let me comment on the funding issue. We 
did some quick numbers, and it appears that AHCPR's budget is 
like about 1 percent of what NIH's budget is. From the consumer 
viewpoint, we just do not think that is enough.
    The kinds of information that consumers are beginning to 
demand are exactly the kinds of information that AHCPR is 
developing and providing both to practitioners and to 
consumers. We have a major--to try and address your specific 
question a little more precisely--we have a very difficult role 
ahead of us in getting consumers ready to understand the 
information that is being developed.
    I would argue practitioners are not even in tune with a lot 
of the most recent up-to-date outcomes research that is being 
done. There is certainly a role in the different health care 
systems to bring practitioners up to snuff. The Consumer 
Coalition has been working to develop ways to train consumer 
advocates and consumers about report cards and the options that 
they will have, but we have a long way to go. If we don't keep 
funding this kind of information development and synthesis and 
dissemination, both among consumers and practitioners, we will 
reach a point down the road where we will actually have 
consumers who are demanding a lot more than is available. And 
that is why I think, even though a lot of consumers may not be 
able to pull some of the reports off the shelf from the 12 
centers and understand where they are in terms of their health 
care decisionmaking, we will reach a point where the work done 
will be widely used by millions of consumers in their 
decisionmaking and, of course, in the give and take that they 
have with their physicians and health plans about their 
treatment regimen.
    Mr. Brown. I yield back.
    Mr. Bilirakis. I thank the gentleman. Mr. Deal.
    Mr. Deal. Thank you, Mr. Chairman. I have listened and read 
the summaries of what the agency does, and I want to play the 
devil's advocate. As I have listened to what you say the 
functions really are and read those, by and large it is a 
public dissemination agency. I want to ask you if we could not 
better spend the $200 million annually to educate physicians or 
to put it into pure research through NIH. All of this public 
information dissemination is in a context that presumes that 
the private market and the free enterprise system won't work. 
We have underwriting laboratories that do the same kind of 
testing in some degree with products. We have the so-called 
Good Housekeeping Seal of Approval that everyone wants for 
their product in order to sell it. We have consumer reports 
that do an analysis of things that are available.
    Why should the government in this one area have the 
responsibility of being that public information filter. Why is 
the private sector not able to do it?
    Second, in your written testimony, Mr. Lindberg, you said 
part of the function here is to reveal medicine's hidden 
secrets, medical uncertainty, practice variations and the 
limitations of medicine. That does not make a hill of beans 
difference if there is nothing available to you. The 
information of dissemination presumes that the consumer has a 
choice.
    In parts of my district, the consumer has no choice. There 
are few doctors in rural areas. If there are doctors, it is 
very difficult to get an appointment with them. So my real 
question is what difference does it make that you are well 
informed about various options that are out there if you don't 
have a doctor who can provide the service? As I said, it is a 
question posed as the devil's advocate, but I think it is one 
worth asking. We are a Nation of limited resources. We are a 
government of limited resources. Why couldn't we simply train 
physicians with $200 million a year?
    Mr. Kahn. First, I think it is important to point out that 
the agency develops the means of analyzing various types of 
treatments for conditions, and that is a different function 
than what NIH generally does, which is to deal with the hard 
science, sort of the underlying factors that lead to various 
kinds of physical ailments and occurrences. And I guess I would 
argue that the culture at NIH is different than what we need in 
this kind of agency. So this agency is justified, in a sense, 
to be separate from NIH.
    Mr. Deal. Why could that function not be fulfilled by the 
medical schools and by the specialties within the medical 
community that has as part of their purpose to disseminate that 
kind of information?
    Mr. Kahn. It is actually the collection of data and doing 
research on whether it is various kinds of treatments for heart 
ailments or other treatments, so it is more than just 
dissemination. An example, many years ago I worked for Senator 
Quayle in the Senate and he developed legislation. And at that 
point--this was in the early eighties, the buzz word was 
technology assessment; it wasn't outcomes research. But in 
those days he developed legislation, and it was passed that set 
up or tried to set up in the National Academy of Sciences a 
clearinghouse for information about technology assessment. In a 
sense, that was just going to be dissemination.
    The legislation was designed to bring together the medical 
community and the various user communities, whether insurance 
or others, and it didn't work. It really was an attempt to have 
a little Federal seed money, but basically to have a private 
sector clearinghouse on technology assessment. And it didn't 
work, I think, because there wasn't strong leadership. There 
wasn't--and there also wasn't the one thing that you have in an 
agency like this, which is a clear mission and sort of the 
assurance of an ongoing activity, an ongoing line of funding at 
a sufficient level to do things like drawing the right people 
together and setting an agenda on which conditions ought to be 
looked at first.
    And so I guess my argument would be that in some small ways 
some of the things that you are describing have been tried and 
have failed.
    Second, on any given day I am not going to argue that a 
foundation, Johnson Foundation or others, will not come in and 
fund X activity, but it is very difficult to get that ongoing 
year in year out that you are going to get from this kind of 
agency. I guess that would be my answer to you.
    Mr. Lindberg. Mr. Chairman, may I comment on it as well?
    Mr. Bilirakis. If you do it briefly.
    Mr. Lindberg. First I would like to argue that there is a 
public health responsibility that the Federal Government has 
here.
    I believe we need to assure that the best care is being 
provided, that the research that directs that care has been 
validated. So we can't just assume in this case, I don't 
believe, that the private sector will do that.
    With regard to the rural setting, I think most of us are 
very sympathetic to that, the issue of getting more physicians 
and other health care providers into those settings, and that 
that should be done and there should be efforts to do that. But 
even the physician in the rural area that you have a hard time 
getting into see, I would argue he may or she may be even more 
likely not to have all of the cutting edge tools at his or her 
disposal. And, therefore, the work of an AHCPR which would help 
provide the research that would lead to guideline development 
by a professional society, for example, that that physician 
uses is still benefiting that community because if an 
individual patient goes in there and gets the wrong treatment, 
it may be just as bad or worse than not getting any treatment 
at all.
    Mr. Deal. I would rather see a doctor who may not have the 
latest technology than not to be able to see a doctor at all, 
and sometimes that is the choice.
    Mr. Bilirakis. Ms. Eshoo to inquire.
    Ms. Eshoo. Thank you for having this hearing in 
anticipation of the bill you introduced with Sherrod Brown to 
reauthorize the AHCPR. And thank you to the panelists. I was up 
at the rules committee and I missed the first panel.
    Is there anything that you think needs to be dropped from 
the mission in the drafting of the bill or added to the mission 
of the AHCPR to improve upon these extraordinary things that 
each one of you have touched on here? So that is just my first 
question to each one of you.
    My second question I want to direct to Dr. Mahan.
    Mr. Lindberg. I will take a quick shot at it. We concur 
with the mission--and I can't recall the specific language in 
the mission that relates to outside input, but I would always 
promote a defined external role for consumer and consumer 
advocate input into the process.
    Dr. Eisenberg talked about bringing people in and talking 
about what their needs are, and he has done that with 
consumers, and I promote to the extent necessary making that a 
statutory requirement because I think it is critically 
important, and he agrees.
    Mr. Kahn. I think over the 10 years the mission has been 
honed. And the agency is basically now a facilitator as well as 
an agency that funds and sponsors research and then 
disseminates results. So I think the agency is on target and it 
is just time to reaffirm what we have learned over the last 10 
years.
    Ms. Woolley. It is consistent with the kind of public 
opinion polling and focus group testing that we conduct that 
the agency--that anywhere and everywhere it can be emphasized 
that the agency is interested in evidence-based delivery of 
health care. That research is driving it, that would fit very 
well into the public's expectations and their hopes for the 
future of health care.
    Ms. Eshoo. Reliable information for reliable care, right?
    Ms. Woolley. Yes.
    Ms. Eshoo. Doctor, you gave superb testimony, and I am 
moved by what you said. I always get excited to hear from the 
best successes. You offered a great deal to us. I don't know if 
there might be another setting at some point, Mr. Chairman, 
with our subcommittee, to explore some of the things that you 
experienced, about some of the things that you integrated when 
you went to Disney. I am very interested in what you said.
    I want to pay tribute to our Chairman in the work that he 
did to erase those horrible numbers in terms of infant 
mortality. That is really one of the great measures, yardsticks 
of how a society is measured. And I salute you for the work 
that you have done.
    Can you give us an example of how the AHCPR--define the 
nexus between the work that you have done and the outcomes that 
are experienced and relate them back to what the agency has--
how the agency has assisted you in that effort?
    Mr. Mahan. Yes. I think it falls in the category of the 
quality improvement that Dr. Eisenberg pointed out. I think it 
is very important, as I said, when you talk to any of us of any 
income level or education level about quality and health care, 
a lot of what we add on to that is how we were treated.
    I think that the agency can certainly add that in as a 
measure of quality. It is tricky. I mean, asking people right 
after they have seen a doctor, Were you satisfied with your 
care? Well, they have already been there and most of the time 
they are satisfied. The trouble is that we are asking the 
people already going for care. What we need to do is get out to 
the folks that are using emergency rooms as their main source 
of care and say why are you doing this. Then we find out that 
there is a whole other shadowy part that we need to research as 
part of quality and access.
    Ms. Eshoo. I appreciate what you've said, and I salute each 
one of you for your work. I for one am very glad that the 
agency was not eliminated in 1995, and I think each one of you 
have very unique perspectives, and there seems to be resounding 
applause for what the agency does and what its mission is.
    Mr. Chairman, I look forward to your bill and our ranking 
member's bill for reauthorization because I think this is an 
agency that is serving the Nation very, very well.
    Mr. Bilirakis. I thank the gentlelady. And obviously, the 
testimony that we have heard today is going to be a helpful 
factor in that regard.
    I might add that we are going to be visiting the NIH in 
June and also the CDC in Atlanta. We may be able to go see the 
healthy mothers and babies operation in the Tampa, Florida 
area. We will work on something like that.
    We have talked a lot about research. We have talked about 
biomedical research and of course this research that the agency 
does which ties in, obviously. I think that most of us, if not 
all of us, are committed to doubling, certainly increasing, the 
research funding over the next few years. The BRAVO Act is 
something that we hope will help supplement that funding.
    So we would need you all to help us out in that regard in 
getting the cosponsors that it will take.
    Chip, Ways and Means has been the problem insofar as the 
BRAVO Act is concerned.
    Mr. Kahn. I don't work there any more.
    Mr. Bilirakis. But you still have some influence there. 
Your face is red, and it should be.
    Anything further, Mr. Brown?
    Mr. Brown. No.
    Mr. Bilirakis. That being the case, you have been an awful 
lot of help, and we really appreciate your taking the time to 
be here.
    [Whereupon, at 11:45 a.m., the subcommittee was adjourned.]
    [Additional material submitted for the record follows:]
   Prepared Statement of The Association of American Medical Colleges
    The Association of American Medical Colleges (AAMC) strongly 
supports the reauthorization of the Agency for Health Care Policy and 
Research (AHCPR). The AAMC represents the nation's 125 accredited 
medical schools, some 400 major teaching hospitals and health systems, 
86 professional and scientific societies representing 87,000 faculty 
members, and the nation's medical students and residents.
    Complementing the medical research conducted at the National 
Institutes of Health, AHCPR sponsors health services research designed 
to improve the quality of health care, decrease health care costs and 
provide access to essential health care services in a rapidly changing 
market. In addition, the agency has made a major commitment to the 
advancement of evidence-based medicine.
    As the lead federal agency to improve health care quality, AHCPR's 
overall mission is to support research and disseminate information that 
improves the delivery of health care by identifying evidence-based 
medical practices and procedures. AHCPR supports a number of research 
initiatives designed to enhance consumer and clinical decision making, 
provide improved health care services, and promote efficiency in the 
organization of public and private systems of health care delivery. To 
build an evidence base for clinical practice, AHCPR funds twelve 
Evidence-based Practice Centers to review relevant literature about 
selected topics and publish evidence reports summarizing such 
information. In an effort to improve medical outcomes, AHCPR supports 
studies to evaluate the effectiveness of treatment strategies for many 
of the country's most prevalent and costly diseases.
    The AAMC firmly believes in the value of health services research 
as this nation continues to strive to provide high-quality, efficient, 
and cost-effective health care to all of its citizens. Consequently, we 
believe that the agency's budget should be increased substantially to 
accomplish this critical mission.
    In conclusion, the AAMC emphasizes the essential linkage between 
robust support of health services research and support for medical 
research to ensure that the benefits of basic and clinical medical 
research will flow to all Americans. We appreciate the attention the 
Subcommittee on Health has given to the agency at the April 29 
reauthorization hearing and look forward to working with the 
Subcommittee as the reauthorization legislation moves through Congress.
                                 ______
                                 
      Prepared Statement of American Academy of Family Physicians
    The 88,000 member American Academy of Family Physicians would like 
to submit this statement for the record on an issue of critical 
importance to our organization: the need for strong support for primary 
care research at the Agency for Health Care Policy and Research 
(AHCPR). We look forward to working with you as the Committee 
reauthorizes this agency.
Support for the Agency for Health Care Policy and Research
    The Academy is a long-time advocate of the Agency for Health Care 
Policy and Research. The AAFP supported AHCPR's establishment and, in 
particular, the agency's statutory authority to support clinical 
practice research, including primary care and practice-oriented 
research. In fact, the 1992 Senate Report 102-426 accompanying P.L. 
102-410, which reauthorized AHCPR, states that the Agency should 
strengthen its commitment to family practice and primary care research. 
The report asserts that,
        ``The committee believes that inadequate attention has been 
        given to conditions that affect the vast majority of 
        Americans--that is, the undifferentiated problems individuals 
        present to their generalist physicians. A focus on family 
        practicel/primary care research is essential if we are to 
        redirect the US health care system that is currently skewed 
        toward high technology medicine for catastrophic diseases.
    The Center for Primary Care Research at AHCPR, whose mandate is to 
support research in primary care, is the centerpiece of the agency's 
work in this area. It is the only federal agency with this charge.
Need for Primary Care Research
    American medicine is praised worldwide for its excellence in 
biomedical research. While in the past we have invested heavily in new 
technologies, drugs and procedures, they are increasingly being viewed 
as very costly advances for increasingly modest gains. We have also 
seen overutilization of expensive interventions and learned that all 
new developments have both benefits and harms. Part of primary care 
research is determining the appropriate way to use the knowledge that 
has been developed in a manner that helps improve quality and meets 
patient needs. It is not enough to develop new treatments; we must also 
ensure that they can be implemented and actually result in improved 
patient outcomes.
    In addition, the medical community has often been unable to 
translate breakthroughs in new technologies, drugs and procedures to 
practical treatments that became readily available to the population at 
large. This is in part because what may appear to be promising in the 
laboratory or in highly controlled clinical trials undertaken in 
university centers may not be practical when attempted in the real 
world, or may work differently in different settings or with different 
population groups.
    While most medical care is provided in the outpatient setting, 
ambulatory medicine is the least researched mode of patient care. Over 
95 percent of all medical conditions have been evaluated and treated 
outside of hospitals over the last 30 years. Nevertheless, physicians 
today are educated and trained using research information that has 
largely been derived from hospitalized patients, or patients with 
conditions in an advanced state.
    Consequently, the formal knowledge base used by physicians is 
derived principally from the impatient treatment of those who have 
selected serious health conditions. Primary care physicians whose 
principal responsibility is to diagnose and treat such conditions 
before they require inpatient care all too often must proceed without 
anywhere near the level of research-based assurance that their 
subspecialist colleagues can utilize. Indeed, American health care is 
increasingly biased toward institutions and systems that use highly 
technological methods to treat catastrophic and end-stage disease.
    This bias is evident in the dramatic difference in funding for FY 
1999 for the National Institutes of Health (NIH). The NIH currently 
receives $15.6 billion and, by contrast, funding for the AHCPR is $171 
million, slightly over one percent of the nation's biomedical research 
budget.
    According to the 1996 Institute of Medicine (IOM) report on primary 
care, Primary Care: America's Health in a New Era, federal investments 
in primary care research today total between $15 and $20 million 
annually. The IOM report recommended an immediate fourfold increase in 
primary care research. We believe that U.S. research facilities must 
complement their understanding of high-tech research with a similar 
dedication to applying state of the art medicine to understanding 
primary care. We need to rebalance the research investment to meet 
today's health care needs.
Primary Care Research Agenda
    It is essential that increased funding for primary care research 
needs to be guided by a clear agenda. This agenda should include a 
number of components, including research to determine the origin of 
disease and the loss of health, and research to improve diagnostic 
accuracy, appropriate treatment, the physician-patient relationship, 
health care delivery, and patient satisfaction. It must also include 
investments in the necessary infrastructure for primary care research, 
such as training programs. This agenda is described further in the 
widely distributed AHCPR report, Putting Research into Practice: Report 
of the Task Force on Building Capacity in Primary Care, 1993
    Regarding improved diagnostic accuracy, we know that most 
individuals present their physicians with a cluster of ill-defined 
symptoms. It is the responsibility of the family physician to make 
sense out of these symptoms and determine whether they constitute a 
short-term problem or one requiring ongoing or intensive treatment. 
Primary care research would assist physicians in streamlining the 
diagnostic process and increasing accuracy of diagnoses.
    A primary care research agenda would include a significant emphasis 
on treatment plans, especially for problems with the poorest prognoses. 
As family practice and the new health system seek to adopt evidence-
based approaches to clinical care, we frequently find that the research 
has not been completed that answers these key questions. The 
development of outcomes-based clinical policies and of evidence-based 
quality measures has been thwarted by the lack of appropriate research. 
In the absence of such studies, ``expert'' opinion and experiential 
decision-making has been used to develop treatment plans. Primary care 
research can clarify appropriate treatment plans, as well as reduce the 
potential for use of expensive, unnecessary or potentially dangerous 
medical tests.
    Because of the paucity of research in this area, the Academy 
strongly supports the Evidence-based Practice Centers (EPCs) funded by 
the AHCPR. The purpose of the centers is to review the science around a 
number of specific topics and use this information to develop reports 
on effective treatment in the practice setting. These reports will be 
practical tools for practicing clinicians and health care systems. 
These analyses will also be extremely useful in helping specialty 
societies develop clinical guidelines and quality measures. According 
to John M. Eisenberg, MD, AHCPR Administrator, ``These state-of-the-
science reports and technology assessments, once distributed, will help 
reduce inappropriate variations in medical care and improve the overall 
quality of the health care system.''
Quality Issues
    The growing interest in primary care research is integrally related 
to the recent attention to measuring the quality of health care. The 
changing shape of American health care, with its movement away from 
fee-for-service medicine to a variety of managed care systems, has both 
exacerbated concerns about quality and made primary care research more 
relevant. More generally, physicians, health plans and researchers are 
still seeking answers to the questions, ``What defines health care 
quality? What are the best health care outcomes? How do we measure 
quality?''
    In a May, 1997, article in the Journal of Family Practice, Primary 
Care Research: Current Challenges, Future Needs, the author states: \1\ 
``This change has sparked increasing interest among managed care 
organizations in knowing how to provide primary care services in the 
most efficient and effective manner . . . At the same time, widespread 
efforts by managed care companies to reduce the cost of health care 
services have created public concern that quality of care is being 
jeopardized.'' The resulting desire by MCOs to provide quality, 
effective care to their members relies heavily on the answers provided 
by primary care research.
---------------------------------------------------------------------------
    \1\ Lanier, D. and Clancy, C. Primary Care Research: Current 
Challenges, Future Needs. Journal of Family Practice May 1997; Vol. 44; 
434-43 8.
---------------------------------------------------------------------------
    The Academy is strongly committed to health care quality 
improvement and believes that primary care research is an important 
basis of efforts to improve health care quality. In fact, the AAFP's Ad 
Hoc Committee on Quality Assessment and Improvement recommended 
recently that AAFP partner with other researchers, for example, at 
AHCPR, to study the efficacy of quality improvement programs. This 
project would include determining effective ways to change physician 
behavior or patient behavior, guideline compliance, effectiveness of 
quality measurement and improvement programs, and developing a plan to 
influence researchers to study the areas determined to be important.
Examples of Primary Care Research Needs
    The following two examples illustrate the types of questions that 
could be answered by primary care research.
    Family physicians see patients every day in their practices who 
suffer from multiple diseases. An example of this comorbidity is the 
patient with diabetes, hypertension, depression, low back pain and 
heart disease. However, traditional, disease-specific treatment is not 
useful in this situation; treatment for one disease may exacerbate the 
other conditions. Primary care research is needed to provide 
information to physicians on the most effective treatment plans for 
patients with numerous, serious conditions.
    A second example of a question to be potentially explored by 
primary care research involves the 20 million Americans who suffer from 
headaches. While headaches afflict millions of individuals, the primary 
care physician has little information on how to identify the few who 
suffer from life-threatening illness. Research is needed on 
differentiating the common headache from one with serious implications.
AAFP Research Initiative in Family Practice Research
    In September, 1997, the Academy announced a major, new initiative, 
committing nearly $8 million to a multi-year program to stimulate the 
infrastructure to conduct family practice research. Not only was this a 
culmination of long-standing concern about the underfunding of research 
in primary care, but an indication to the field that this research was 
simply too important to wait. The size of the commitment underscores 
the Academy's real concern that primary care research is a critical 
piece of the nation's research agenda.
    The AAFP initiative includes five components to address the need to 
enhance family practice research: partial support of research centers; 
funding to increase the pool of quality family practice research in the 
form of advanced research training opportunities; funding for support 
of practice-based research networks; development of partnerships with 
managed care organizations to jointly fund research and/or research 
related projects and advocacy. We would also like to work with AHCPR on 
a national research conference. It is our hope that this initiative 
will encourage much more significant efforts at the federal level to 
support primary care research and will complement these efforts, as 
well.
Conclusion
    The need for an increased emphasis on primary care research is 
acute. Both individual physicians and the health care system will 
benefit greatly from science-based, quality information about what 
works in the clinical practice setting. We look forward to working with 
you and the Agency for Health Care Policy and Research to enhance and 
stimulate work in this area.

                                   - 
