[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.
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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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