[Congressional Record Volume 141, Number 88 (Thursday, May 25, 1995)]
[Senate]
[Pages S7575-S7576]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]


             THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH

 Mr. ROCKEFELLER. Mr. President. I would like to submit for the 
Record, a recent Washington Post article on the Agency for Health Care 
Policy and Research (AHCPR).
  Before submitting the article, I would like to say a few words about 
the AHCPR. The Agency for Health Care Policy and Research (AHCPR) was 
established as the eighth agency in the Public Health Service by the 
Omnibus Budget Reconciliation Act of 1989. I was pleased to work on a 
bi-partisan basis--with Senators Mitchell, Hatch, Durenberger and 
Kennedy, and Representatives Gradison, Stark, and Waxman--to help 
establish AHCPR.
  In creating the agency, Congress gave increased visibility and 
stature to the only broad-based, general health services research 
entity in the Federal Government--one of the most important sources of 
information for policymakers and private sector decisionmakers as they 
seek to resolve the difficult issues facing the Nation's health care 
system.
  Congress gave AHCPR the following mission:

       ``to enhance the quality, appropriateness, and 
     effectiveness of health care service and access to such 
     services, through a broad base of scientific research and the 
     promotion of improved clinical practice and in the 
     organization, financing and delivery of health services.

  The Members of Congress who supported the creation of AHCPR did so 
because of their concern that while the Nation was spending at that 
time some $800 billion on health care, it is now more than a trillion 
dollars, we had little information on what works in the delivery or 
financing of care. We wanted to encourage support for research to find 
the best ways to finance and provide health care at the lowest cost and 
the highest quality. We believed then that for a relatively low 
expenditure we could find ways to save health care money without 
sacrificing quality. The AHCPR's work has proven us right.
  The 1989 Reconciliation Act authorized AHCPR to conduct research in 
three basic areas: Cost, Quality, and Access (CQA) and medical 
effectiveness research and outcomes research.
  Cost, Quality and Access research funding has provided:
  The fundamental research that led to the development of the Diagnosis 
Related Groups (DRG) system;
  The basic research that first documented major variation in physician 
practice patterns;
  A landmark study, called the Medical Outcomes Study
   (MOS) which will help understand the impact of financial incentives 
and practice setting (e.g. Health Maintenance Organizations vs. fee-
for-service) on practice style and, in turn, on health outcomes;

  Research that documented that utilization review can significantly 
cut utilization costs of health care; and
  The most comprehensive survey on the costs and utilization patterns 
of AIDS patients, which will help target treatment programs, more 
effectively.
  Part of AHCPR's work is in technology assessment and this effort has 
made a significant contribution to saving federal funds. For example, 
according to the Institute of Medicine, at least $200 million a year in 
medicare expenditures are saved through AHCPR's technology assessment 
program. Again, AHCPR is helping us as policymakers understand what 
works.
  Congress greatly expanded the federal effort to support research on 
the outcomes, appropriateness and effectiveness of health care 
services. The ultimate goal of this program is to provide information 
to health care providers and patients that will improve the health of 
the population and optimize the use of scarce health care resources. 
This program includes research, data development and development of 
clinical practice guidelines.
  It was our hope that the guidelines, which are just that, not 
requirements, would lead us to find ways to save money without 
compromising care. It is now apparent that our modest investment in the 
process has paid off.
  For example, AHCPR, research has found that some 90% of low back pain 
problems--a condition estimated to cost more than $20 billion a year in 
health expenditures--disappear on their own in about one month. This 
finding has enormous cost savings implications.
  One hospital in Utah found that after six months of using an AHCPR 
guideline on prevention of pressure ulcers that it saved close to 
$250,000. That hospital is part of the Intermountain Health Care system 
which has now implemented the guideline in its 23 other hospitals. Use 
of this guideline has reduced the incidence of bed sores by 50% at 
savings of $4,200 per patient. [[Page S7576]] 
  I cite the cost savings aspects of AHCPR research because of a 
recommendation by the Budget Committee to cut AHCPR research by 75%. 
The committee report also indicates that AHCPR was established to 
manage health care reform. That assertion is just plain wrong. AHCPR is 
an important agency for its research, but it was not envisioned to be a 
health care
 implementation agency. We may save a few Federal dollars by cutting 
AHCPR's funding, but we will lose far more in potential savings in our 
health care system.

  The budget resolution also proposes deep reduction cuts in Medicaid 
and Medicare spending. I oppose those harsh cuts because the people of 
West Virginia will have health care benefits taken away from them as a 
result. It seems to me that the only way to rationally reduce costs and 
not hurt people by reducing their access to care or their quality of 
care, is to know what works and what does not work. That is precisely 
the point of the research of AHCPR.
  The current budget of AHCPR is about $160 million. This modest 
investment is just now paying off in research and guidelines which have 
the potential to reduce cost and without a reduction in quality of 
care. It is my hope that the Appropriations Committee will continue to 
provide adequate appropriations for AHCPR and I will do my best to 
support the agency as the Congress makes its decisions on 
authorizations and funding for the coming fiscal year.
  I ask that the article from the Washington Post be printed in the 
Record.
  There being no objection, the article was ordered to be printed in 
the Record, as follows:

                [From the Washington Post, May 15, 1995]

     House Panel Would Kill Agency That Compares Medical Treatments

                            (By David Brown)

       It doesn't take long to go from being a solution to waste 
     to simply waste.
       That, at least, is the congressional budget committees' 
     view of the Agency for Health Care Policy and Research. The 
     $162 million agency is the government home for ``medical 
     effectiveness research.''
       When it was created by Congress in 1989, the AHCPR was 
     viewed as an essential tool in the effort to control medical 
     costs without damaging medical care. Last week, the Senate 
     Budget Committee proposed cutting its budget by 75 percent, 
     and the House Budget Committee said it should be eliminated 
     altogether.
       AHCPR was launched with the great hope--much of it 
     enunciated by politicians--that it would help the country cut 
     health care costs painlessly by comparing competing treatment 
     strategies to see which works, best, and at the least cost.
       Over the last five years, the agency has sponsored 20 
     Patient Outcomes Research Team (PORTs), each headquartered at 
     a different hospital or university, which studied such topics 
     as back pain, schizophrenia, prostate enlargement, knee joint 
     replacement, cataracts, breast cancer and heart attack.
       The teams reviewed the published medical literature on the 
     topic, delineated the variations in treatment, attempted to 
     uncover links between specific treatments and patient outcome 
     (often using large data banks kept by Medicare or private 
     insurance companies), and occasionally devised new tools. For 
     example, the prostate PORT created a video to educate 
     patients about what to expect with certain treatments--
     including no treatment--and formally incorporated the tool 
     into medical decision-making.
       Recently, AHCPR has begun funding randomized controlled 
     trials, which are generally the best way to compare one 
     treatment with another. The topics are ones unlikely to 
     appeal to the National Institutes of Health, where new 
     therapies, not old ones (or low-tech ones), are the preferred 
     subjects of clinical research.
       AHCPR trials, for instance, are comparing chiropractic 
     treatment to physical therapy in low back pain; testing a 
     mathematical equation that identifies which patients are most 
     likely to benefit from ``clot-busting'' drugs for heart 
     attacks; and comparing homemade vs. commercial rehydration 
     fluids for children with diarrhea.
       The agency also has sponsored 15 ``clinical practice 
     guidelines,'' which, based on the best medical evidence, 
     suggest how to treat such common (and unexotic) problems as 
     cancer pain, urinary incontinence and chronic ear infections.
       In a recent example of that program's effects, researchers 
     at Intermountain Health Care System in Utah reported they had 
     cut the incidence of bedsores in high-risk (generally 
     paralyzed) patients from 33 percent to 9 percent at LDS 
     Hospital in Salt Lake City after implementing a modified 
     version of AHCPR's guideline on pressure ulcers. Incidence of 
     ulcers--which cost an average of $4,200 to treat--also fell 
     among lower-risk patients, and the hospital estimated the 
     annual savings will be at least $750,000.
       To defund a relatively modest effort like that at a time 
     when the questions they need to answer are becoming even more 
     critical doesn't make a lot of sense to me,'' said Jay 
     Crosson, an executive in charge of quality assurance at 
     Permanente Medical Group, the physician organization of the 
     Kaiser Permanente health maintenance organization (HMO). 
     There's a lot more work that needs to be done than even AHCPR 
     can fund.''
       In explaining its recommendation of a 75 percent budget 
     cut, the Senate Budget Committee said AHCPR ``was to be the 
     primary administrator of comprehensive health reform''
       This, however, is not true. Although data-gathering by 
     AHCPR-funded researchers presumably would have helped assess 
     the equity of a national health care program, the agency had 
     not official role in the defunct Clinton administration 
     plan.
     

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