[Congressional Record Volume 141, Number 136 (Tuesday, September 5, 1995)]
[Senate]
[Pages S12608-S12610]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




     THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH: A BEACON FOR 
                              POLICYMAKERS

  Mr. DASCHLE. Mr. President, as the Congress considers its 
appropriations bills and strives to reduce the rate of growth of 
Federal programs, I would like to call attention to one very small, but 
important agency that policymakers and industry representatives alike 
have praised as responsible and cost-effective--the Agency for Health 
Care Policy and Research [AHCPR].
  AHCPR, which is part of the Department of Health and Human Services, 
was established in 1989 with strong bipartisan support. Broadly stated, 
the agency's mission is to conduct impartial health services research 
and disseminate information that will complement public and private 
sector efforts to improve health care quality and contain costs.
  AHCPR's charge is to find out what works and what does not work in 
the health care system, and the results of its research are being used 
voluntarily by the private sector to contain health care costs. The 
agency funds outcomes research projects that examine the efficacy of 
medical interventions in terms of how they affect patients. It also 
funds studies on the medical effectiveness of particular procedures and 
conducts assessments of health technologies utilized by HCFA and 
CHAMPUS to make coverage decisions. These projects have identified 
millions of dollars in potential savings to Medicare. Finally, the 
agency convenes multidisciplinary panels of experts to develop clinical 
practice guidelines on such topics as low back pain, cataracts, sickle 
cell anemia, mammography, unstable angina, and cancer pain. These 
guidelines are disseminated to consumers, private and public sector 
health care policymakers, providers, and administrators for use as they 
see fit.
  AHCPR is a true public/private partnership designed to improve the 
quality of health services and contain their cost. And it is working. 
Supporters of the agency include conservatives and liberals in both 
political parties and span the health care spectrum, from the insurance 
industry to providers to academia and other highly regarded public 
policy institutions. AHCPR has been called an ``honest broker'' because 
of the way it compiles and distributes health care cost and quality 
information among competing public and private sector interests.
  It is very important to the health care system that AHCPR continue 
producing the kind of significant research it has developed in the past 
5 years. To slash AHCPR's funding now would truly be penny-wise and 
pound-foolish: The current funding level for the agency amounts to a 
little more than a dollar per American. Yet potential savings from the 
use of its guidelines and research could save hundreds of millions, and 
by some estimate billions, of dollars.

[[Page S 12609]]

  AHCPR should continue to play a critical role as we struggle to 
control national health care costs, particularly in the Medicare and 
Medicaid programs. AHCPR-funded research has provided strong evidence 
that health care costs can be contained while improving the quality of 
services. It would be irresponsible to devastate funding to the only 
Government agency devoted to finding ways for us to improve quality and 
lower costs.
  Recently three of our esteemed former colleagues who were intimately 
involved in the creation of the Agency for Health Care Policy and 
Research--Senator George Mitchell, Senator David Durenberger and 
Representative Willis Gradison--jointly authored an article entitled, 
``The Agency for Health Care Policy and Research: A Beacon for Policy 
Makers.'' This article gives a historical perspective and summarizes 
the current situation while making a persuasive argument for the 
AHCPR's continued funding. I ask unanimous consent that this article be 
printed in the Record, and I urge my colleagues to carefully consider 
these noted health care experts' comments and weigh their advice when 
the Senate considers the fiscal year 1996 Labor-HHS appropriations 
bill.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

     The Agency for Health Care Policy and Research: A Beacon for 
                              Policymakers

(Jointly authored by: former Senate Majority Leader George Mitchell, LL 
B., Georgetown University, B.A. in history, Bowdoin College, currently 
   special counsel to the Washington, D.C.-based law firm of Verner, 
      Liipfert, Bernhard, McPherson and Hand; former Senator Dave 
 Durenberger, J.D., University of Minnesota, B.A. cum laude political 
 science and history, St. Johns University, currently senior counselor 
 for the Washington, D.C.-based public affairs consulting firm of APCO 
Associates Inc.; and, former Representative Willis Gradison, MBA, Ph.D 
  in economics, both from Harvard, currently president of the Health 
          Insurance Association of America, in Washington, DC)

       Reasonable people--including the three of us--may disagree 
     about how to address problems in the nation's health care 
     system and the role government should play in ensuring access 
     to health care for American citizens. But there are some 
     major areas of bipartisan agreement as well. We agree that 
     the quality of health care should not be compromised and that 
     we must get the best value for the trillion dollars we spend 
     each year on medical care.
       One clear way to maximize the value of health care is to 
     create a body of objective, science-based information on the 
     interrelationship of the cost and quality of health care. In 
     the late 1980s, we agreed that a federal investment was 
     needed in health services research. Our thoughts were 
     influenced by the early findings from research funded by the 
     National Center for Health Services Research (NCHSR).
       For example, the ``small-area analysis'' conducted by John 
     Wennberg and others, and the work of the Maine Medical 
     Foundation, showed wide variations in the type and intensity 
     of medical care provided in different parts of the country. 
     Were people in some areas getting too much care? Were others 
     being under treated? To a large extent, we simply lacked the 
     research tools needed to explain these variations. Early 
     research by Wennberg and others also suggested that providing 
     physicians with credible, high-quality information could 
     modify their behavior, improve quality and reduce costs by 
     eliminating unnecessary or ineffective procedures.
       While many public and private groups had initiated their 
     own health services research, their efforts were not being 
     coordinated and there were no scientifically-based protocols 
     for research and guideline development. We concluded that a 
     new agency could become the focus of federally-sponsored 
     outcomes studies. This new agency also would elevate the 
     status of health services research in general. Through 
     bipartisan efforts in both chambers, legislation was enacted 
     to create the federal Agency for Health Care Policy and 
     Research (AHCPR). This legislation ultimately became an 
     important part of the Omnibus Budget Reconciliation Act of 
     1989 (P.L. 101-239).
       As noted in a recent historical account of AHCPR, a primary 
     purpose of OBRA 1989 was to improve quality and contain costs 
     in the Medicare program--to curb costs without having to cut 
     back on needed care. Since both the public and private 
     sectors were calling for more readily available information, 
     AHCPR's mandate was two-fold: to find out which treatment 
     methods actually work and which ones are inappropriate and 
     therefore not cost effective. Second, we asked the agency to 
     work closely with the private sector--particularly consumers 
     and health care providers.
       Among health care providers, physicians are the key. They 
     are an important group to reach, because they are responsible 
     for making most treatment decisions. It is significant to 
     note that many provider groups supported the creation of 
     AHCPR, including the American Medical Association, the 
     American College of Physicians, and the American Society of 
     Internal medicine. It also should be noted that outcomes 
     research was an important companion to the Medicare physician 
     payment reforms enacted the same year.
       Since the federal government is the largest single payer of 
     health care services in the U.S., we initially asked AHCPR to 
     focus its research on the most common and the most costly 
     treatments for federal health programs such as Medicare and 
     Medicaid. In its first five years of operation, AHCPR has 
     made considerable progress. Its research activities focus on 
     ten of the 15 most common diagnoses for Medicare inpatients, 
     and nine of the 15 most common diagnoses for Medicaid 
     inpatients.
       To date, the Agency has released 16 clinical practice 
     guidelines designed to inform patients and clinicians of 
     ``state of the art'' medicine. These guideline topics range 
     from the management of acute low back pain in adults to 
     treating otitis media in children.
       AHCPR also is funding 15 Patient Outcome Research Teams, 
     known as PORTs. These multi-disciplinary, private-sector 
     groups are created to determine the treatment effectiveness 
     of conditions for which there is widespread disagreement 
     about clinical strategies. Current PORTs are studying 
     conditions ranging from cataracts to low birthweight.
       The research and guideline development are the initial 
     steps. Equally important is making sure those guidelines 
     reach the public. So far, the Agency has distributed 26 
     million copies of its guidelines to clinicians and consumers. 
     By working through partnerships with entities in the private 
     sector, AHCPR has saved $12.6 million in federal reprinting 
     and distribution costs. Private partners have circulated 11.5 
     million reprints of AHCRP-funded guidelines.


                         1. finding what works

       The Agency's work has already produced scientific findings 
     that can improve the quality of health care while 
     constraining its cost.
       AHCPR-sponsored research has demonstrated that about half 
     of the 600,000 patients who receive diagnostic cardiac 
     catheterization as inpatients each year could have the 
     procedure on an outpatient basis.
       Research shows that ordering tests by computer decreased 
     hospital costs by nearly $600 per admission, and reduced 
     average length of stay by almost a day. If this computer 
     system was applied to the entire medicine service, the 
     hospital projected over $3 million in savings per year.
       The use of transurethral resection of the prostate--an 
     operation for benign prostatic hyperplasia (BPH)--has fallen 
     nearly 33 percent, due in part to AHCPR research on prostatic 
     disease and its guideline on BPH. This saves Medicare an 
     estimated $60 million annually.
       AHCPR and its predecessor, NCHSR, have also been 
     instrumental in the early development of major improvements 
     to reimbursement systems. They funded the early design of 
     diagnosis related groups (DRGs), which were adapted for 
     Medicare payment reforms in 1983.
       They also have helped to fine-tune the DRG system over 
     time. This series of payment reforms, in combination with 
     other initiatives (such as the creation of Medicare's Peer 
     Review Organizations (PROs)) has been widely credited with 
     limiting cost increases for Medicare. In addition, many of 
     these reimbursement reforms have been adapted by private 
     sector payers.


                     2. Improving clinical practice

       A second type of research conducted and sponsored by the 
     Agency helps physicians and other care-givers take advantage 
     of clinical and cost-effectiveness information. They enable 
     care-givers to use guidelines and other resources to quickly 
     ascertain treatment options and make more informed decisions. 
     For example:
       Low back pain.--In 1990, the U.S. spent more than $20 
     billion for direct medical costs associated with low back 
     pain. Lower back pain accounted for one-tenth of total 
     Medicare charges in 1987. Billions could be saved each year 
     by using the AHCPR guideline, without any loss in the quality 
     of care provided. For example, Singing River Hospital in 
     Pascagoula, Mississippi, has reduced the average length of 
     stay for surgical patients by one day since 1993, with the 
     help of AHCPR's acute pain management guideline.
       Pressure ulcer prevention.--More than 250,000 hospital and 
     nursing home patients suffer from pressure ulcers. Broad use 
     of the AHCPR-supported clinical practice guidelines on 
     prevention could halve the incidence of this very painful and 
     costly problem. For example, Intermountain Health Care, a 
     Salt Lake City-based health care system, saved $240,000 in 
     six months by using the guidelines in one of its hospitals. 
     Intermountain is now implementing the guidelines in its 
     twenty-three other hospitals. Similarly, Abbott-Northwestern 
     Healthcare System in Minneapolis estimates it would save 
     $288,000 a year by using the guideline. South Suburban, a 
     225-bed hospital in Hazel Crest, Illinois, has halved the 
     number of hospital-acquired pressure ulcers since introducing 
     the guideline two years ago.
       Most AHCPR-funded guidelines are so new that it is too 
     early to assess the extent to which they have been adopted. 
     Preliminary research suggests that many managed care 

[[Page S 12610]]
     entities already use one or more of the AHCPR guidelines. Other groups 
     use the guidelines to improve their internal quality-
     improvement initiatives.


                               The Future

       Like all scientific endeavors, there are no ``quick 
     fixes.'' In its first five years, AHCPR has demonstrated that 
     it is a sound investment for the American taxpayer. In fiscal 
     year 1994, AHCPR's annual operating budget of $162 million 
     represents only one fiftieth of one percent of the nation's 
     $900 billion health care spending. Indeed, all federal health 
     services research activities combined accounted for only 
     one twentieth of one percent of national health spending 
     in 1994.
       Federal and state legislators grappling with spiraling 
     health care spending should be supporting health services 
     research more than ever before. They need this knowledge to 
     help them make sound decisions as new health delivery systems 
     evolve.
       Is federally-sponsored health services research still 
     necessary? We believe the answer is yes, for at least three 
     reasons:
       1. In a market-based delivery system driven by provider 
     competition and consumer choice, the information AHCPR 
     generates is essential--especially to the doctor-patient 
     relationship. Health services research also enables us to 
     study the impact of these delivery changes on quality and 
     access as the public and private sectors struggle to contain 
     health care costs.
       2. AHCPR-funded research provides the economies of scale 
     that can only occur with a comprehensive national study. Both 
     public and private groups benefit from having this 
     information in the public domain. The federal government's 
     willingness to provide ``seed money'' stimulates privates 
     sector research initiatives and magnifies the applicability 
     of the results.
       3. AHCPR acts as an ``honest broker'' in developing the 
     science of health services research. The Agency's authorizing 
     legislation does not allow it to regulate the health care 
     industry, it is not empowered to act as a payer of health 
     care services, and it does not administer a health program. 
     Therefore, it is free from conflicts of interest.
       It is appropriate for the government to have a role in 
     building and sustaining the knowledge base that can meet the 
     information needs of a market-driven health care system. 
     Indeed, AHCPR-funded guidelines are often viewed as the 
     ``gold standard'' of guidelines, and are frequently 
     customized by private entities. For example, UCLA Medical 
     Center, Kaiser-Permanente--Anaheim Medical Center and Saint 
     Luke's Hospital in Kansas City, Missouri are among the many 
     facilities that have utilized AHCPR's acute pain management 
     guideline.
       These findings have acted like a beacon, they show policy 
     makers in advance where problems are developing and provide 
     alternatives for helping to solve these problems. The 
     creation of AHCPR has improved the quality of health care 
     delivered in this country by facilitating health services 
     research and disseminating the results to the public. At the 
     same time, it has proved to be an extremely sound investment 
     for American taxpayers.

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