Good afternoon Mr. Chairman and
Members of the Subcommittee. I am
here for the third and last time as
AHCPR's Administrator to present
the President's budget request for the
Agency.
First, though, I would like to take a
few moments to talk about the
changes that have taken place in the
way we do business, changes driven
by the revolution that has made
managed care the dominant form of
health care in the country today.
The year 1996 will be remembered as
one of the most challenging -- and
productive -- in the seven-year
history of the Agency for Health
Care Policy and Research. Despite
the challenges we have faced,
AHCPR strengthened its position as
the lead Federal agency for health
services research and as a resource
for the public and private sectors for
science-based information.
We have done this in two ways.
First, in order to fulfill the agency's
mission of generating and
disseminating information that
improves the health of Americans,
we tailored our research goals to
address explicitly the myriad of
changes affecting the health care
system. AHCPR's research goals are
to determine what works best in
clinical practice; encourage the cost-effective use of health care resources;
help consumers make more informed
choices; and measure and improve
the quality of care.
Second, in working toward these
goals, we adopted two main
strategies: reemphasizing our
customer focus to ensure support for
the highest priority research, and
aggressively pursuing partnerships to
maximize potential for rapid
implementation of new scientific
evidence to improve care.
CUSTOMERS and PARTNERSHIPS
Our customers, whom I call the five
"P's" (patients/consumers, providers,
plans, purchasers, and policy-makers), have distinct needs, but the
challenges they face overlap. To
provide the information and data they
need to improve the quality and value
of health care services, we
strengthened our position as "science
partner" with the health care industry.
The area of quality provides a perfect
illustration of our role as a science-partner. Private market forces have
transformed our Nation's health care
system, resulting in the reduction in
the rate of increase of health care
expenditures. This reduction in
expenditures has raised questions
about the effect on the quality and
appropriateness of health care. But
the central question is: how can we
measure the quality of patient care in
a way that all of us can understand
and that those who deliver care will
agree is a fair and valid approach?
For example, there may be 38
approaches for measuring the quality
of patient care for congestive heart
failure, but are all of them equally
valid? Do they actually measure
what they claim to measure? And
how can physicians even find out all
of the alternative measures that have
been developed and compare them?
To respond to this need, AHCPR
released CONQUEST -- the
Computerized Needs-Oriented
Quality Measure Evaluation System,
developed by the Harvard School of
Public Health. This tool, the first of
its kind, was designed to make it
easier for our customers to identify,
choose and use clinical performance
measures most appropriate for their
needs. These measures are the core of
clinical quality improvement because
they assess: the appropriateness and
effectiveness of care; the timeliness
and safety of services provided; and
whether the care provided results in
the best outcome that can be
expected for that patient's condition.
CONQUEST includes information
on 53 measure sets developed by a
variety of Federal agencies,
accrediting organizations,
associations, and private sector
organizations.
CONQUEST also helped identify
where new performance measures are
needed. In particular, we learned that
there are few good measures
appropriate for children; the
chronically ill; or assessing care
provided to the disabled or mobility
impaired. To address these needs,
we will continue to sponsor research
to develop and test new quality of
care measures through the Expansion
of the Quality Measures project, or
Q-Span, a research effort to support
development and testing of new
performance measures for specific
conditions such as hip fracture and
asthma.
Recognizing the important role that
the private sector can and must play
in this area, AHCPR is working with
the Joint Commission on
Accreditation of Healthcare
Organizations, the National
Committee for Quality Assurance,
and the Foundation for
Accountability in the development of
a public-private partnership to foster
the development of a Quality
Measurement Network (QMNet).
QMNet will be a dynamic network of
developers and users of measures.
This network will add new quality
measures and clinical information as
they become available, as well as
develop and test new ways to
disseminate information on clinical
quality measures, including:
evaluating ways to make
CONQUEST more user-friendly to a
wider range of audiences; providing
technical assistance to users; and
using a variety of communication
channels (phone, Internet, mail) to
bring users together to share
measures and information on quality.
The goal is to create a
comprehensive, publicly accessible
and user-friendly quality
measurement resource with far more
detailed and comprehensive
information on a wider range of
clinical performance measure. Better
measures, and better data on clinical
performance are the best way to
target improvements in health care
and measure success in meeting
those goals.
EVIDENCE- BASED PRACTICE
I'm also pleased to report that work
on our Evidence-based Practice
Centers, first announced last year, is
well underway. Our Agency no
longer develops clinical practice
guidelines. In another example of
our science partnerships, AHCPR
now works closely with the private
sector by responding to their requests
for the scientific evidence they need
to develop their own quality
improvement strategies. The
Evidence-based Practice Initiative
will support a three-part strategy
incorporating Evidence-based
Practice Centers, a National
Guideline Clearinghouse, and
research and evaluation.
Evidence-based Practice Centers. Established at existing academic
centers, these AHCPR-sponsored
centers will give medical groups,
health plans, purchasing
organizations, states, and others, the
scientific foundation they need to
develop clinical performance
measures and other tools to improve
the quality of health care services.
There are thousands of clinical
studies published every year. Many
offer contradictory findings on the
same condition or medical procedure.
Just as you and I are confused when
contradictory press releases on
improved health advise us both to
abstain from alcohol use and to drink
a glass of red wine daily, so too can
physicians be confused by the vast
amount of sometimes contradictory
information available to them. Few
clinician groups, hospitals, or health
plans have the time or resources to
review each article and evaluate and
compare the appropriateness, clinical
relevance, and strength of its
findings. The EPCs will provide
that service to them.
The Evidence-based Practice Centers
(EPCs) will review and synthesize
the relevant scientific literature, and
develop meta-analyses, evidence
tables, and other products on topics
submitted by public- and private-sector organizations. The Centers
will work closely with these
organizations to ensure that the
materials developed meets their
needs. AHCPR also will
disseminate the information widely
to the medical community as a
whole. The positive response of the
medical community to this initiative
is clear: the American College of
Cardiology and the American
Academy of Pediatrics have already
asked AHCPR to develop two
evidence-based reports. These
reports will serve as the prototypes
for the future work of the centers.
National Guideline Clearinghouse. Discussions are currently underway
with the American Medical
Association and the American
Association of Health Plans to
develop with AHCPR a national on-line clearinghouse of existing public
and private-sector clinical practice
guidelines. This will allow all
clinicians, provider groups, health
plans and systems to obtain
information on about major
published guidelines. The
clearinghouse will include
information gaining access to the
guidelines; summaries, with full text
when available; and annotations that
will permit users to compare the
process by which each guideline was
developed and the extent to which
recommendations of guidelines on
the same topic differ.
Research and Evaluation. AHCPR
will continue its program of research
and evaluation activities on the
development and implementation of
quality improvement initiatives.
Emphasis will be placed on working
collaboratively with health plans and
provider groups.
In combination, these components of
AHCPR's Evidence-based Practice
Initiative will help to ensure that
organizations working to improve the
quality of health care will have
access to the information they need.
HELPING CONSUMERS MAKE
BETTER DECISIONS
In the past two years, we have
strengthened our commitment to
meeting the needs of the patient and
the consumer. We want consumers
to make informed decisions about
their own personal health and to
select the highest quality and most
appropriate health care services. For
a market-based system to work,
consumers need timely, easily
understandable, and reliable
information.
Nearly three-quarters of Americans
covered by employer-based health
insurance were enrolled in managed
care plans at the end of 1995,
compared with only one-half in 1993.
To aid consumers in selecting high
quality health plans and services,
AHCPR supports the Consumer
Assessments of Health Plans Study,
or CAHPS. CAHPS will develop and
test questionnaires and reporting
formats that can be used by public-
and private-sector organizations to
conduct surveys of their members.
These organizations can use the
results to provide prospective
enrollees with the information and
data they need to select high quality
health plans and services.
The managed care explosion is not
limited to the private sector. Federal
programs, such as Medicare and
Medicaid, also are turning to
managed care to contain health costs
and get better value. CAHPS
includes an agreement with the
Health Care Financing
Administration for a module
specifically developed for Medicare
beneficiaries. CAHPS will provide
Medicare beneficiaries enrolled in
managed care organizations the
information needed to make an
informed decision in selecting high
quality health plans and services.
FY 1998 Budget Request
Now I will turn to our plans for the
future. The FY 1998 Budget Request
is $149 million, an increase of $5.5
million over the FY 1997 level. This
increase allows us to fund the Quality
and Cost Effectiveness of Clinical
Care Initiative and to fully fund our
commitments.
I am particularly excited about our
research in the area of quality. We
have focused on quality for the FY
1998 budget as we work to further
the progress we have made in
enhancing the quality of heath care
services. Over the past two years, we
have emerged as the center of a broad
public and private effort to define,
measure, and improve the quality of
care. In fact, Secretary Shalala has
designated AHCPR as the lead
agency in the Department's new
initiative to "Improve Health Care
Quality."
The Quality and Cost Effectiveness
Initiative will focus on developing
knowledge, tools and approaches to
improve the quality of clinical care.
This initiative has two components.
The first component of this initiative
is focused on outcomes,
effectiveness, and cost-effectiveness
research. We will increase scientific
knowledge by supporting outcomes,
effectiveness and cost-effectiveness
research on conditions that are:
common, costly, and associated with
substantial variation in practice; and
research that is identified by out
customers, for which the evidence
base is incomplete or controversial.
Some areas are emerging where
additional research is needed,
including Hormone Replacement
Therapy, Alzheimer's Disease,
common orthopedic conditions, and
clinical conditions, such as asthma
and diabetes, that are common in
children and adolescents.
As I mentioned earlier, research on
quality and cost effectiveness also
plays a crucial role in the continuing
effort to decrease expenditures for
the Medicare program, while
providing quality health care. A
recent publication of an AHCPR-supported patient outcomes research
team outlined a simple and accurate
method to predict which patients
with pneumonia may be treated at
home rather than in a hospital. The
prediction method could help reduce
the over $4 billion spend annually for
inpatient care.
Additionally, the results of one of
AHCPR's pharmaceutical outcomes
studies have shown that elderly
patients who receive beta blockers
following heart attack are 43 percent
less likely to die in the first two years
following the attack than patients
who do not receive the drug. This
study showed that the under use of
beta blockers in this population leads
to an increased rate of hospitalization
and mortality. These are only two
examples of quality and outcomes
research conducted by AHCPR that
helps to reduce Medicare cost and
improve quality of care.
The second component of this
initiative is on quality measurement
and improvement and clinical
performance measures. The demand
for accountability by purchasers and
consumers requires reliable and
usable clinical performance measures
to assess and improve the quality of
care. In addition, as purchasers move
toward direct contracting with
providers, the need for scientifically
sound measures at this level, and not
at the health plan level, becomes
acute. Since an expanded knowledge
base and tools for clinical
improvement are necessary but not
sufficient to change practice, studies
that assess the effectiveness of
strategies to implement these
interventions in actual practice must
also be conducted.
MEPS
I also can report to you that the
Medical Expenditure Panel Survey
continues to be one of our highest
priorities in FY 1998. A total of
$36.3 million is provided for MEPS.
Over the course of the spring, MEPS
data will be used to evaluate the
impact of: growing enrollment in
managed care; enrollment in different
types of managed care; changes in
how chronic care and disability are
managed and financed; changes in
employer-supported health insurance;
and changes in Federal and State
policy.
The current data, gathered through
in-person interviews with 13,500
families, is of vital importance to
managing the Nation's health care
costs. In FY 1998, we will conduct
interviews with approximately 3,000
facilities, 20,000 office- based
providers, and more than 500 home
health providers. In addition, the
MEPS Insurance Component
conducted in FY 1998 will consist of
interviews with more that 40,000
employers and 1,000 insurance
carriers.
MEPS data -- not available from any
other surveys supported by the
Federal government or the private
sector -- is essential for analyzing
issues such as insurance portability,
access to health care, spending by
different population groups, and
changes in overall health care
financing and delivery. Additionally,
the National Nursing Home
Expenditure Survey will provide
calendar year expenditure estimates
for nursing home care for persons
residing in a nursing home anytime
during 1996. The survey will not
only provide expenditure estimates
by sources of payment, the survey
estimates changes in sources of
payment, including Medicaid, over
the year. These data are only the tip
of the iceberg. Over time, MEPS
will provide more comprehensive
data for public and private sector
decision makers, more efficiently,
and assure a better return on the
Federal Government's investment.
GPRA
MEPS was also a logical first step
towards AHCPR's implementation of
the Government Performance and
Results Act of 1993. GPRA requires
that all Federal agencies build
strategic planning and evaluation into
management and development of
their programs, something AHCPR
had done informally and formally for
many years. Although the process of
developing formal program
effectiveness measures for all of
AHCPR's programs is still
underway, for the FY 1998 budget,
AHCPR has developed a pilot
performance plan for MEPS.
The main performance goal for
MEPS is to have the raw data from
the surveys available in March, 1997
for the initial development of
preliminary analytical files. This
goal is important to the success of the
program. MEPS, when it replaced
the National Medical Expenditure
Survey, was designed to provide
more timely data at a lower cost per
year of data. AHCPR also will
assess performance indicators such as
the turnaround time for providing
data for outside use, cost of
collecting the data, new types of data
not previously available, and rate of
requests for public use tapes.
We believe that these goals and
measures will allow AHCPR to
provide a complete picture of MEPS'
performance and program
effectiveness, and we plan to develop
similar performance plans for other
AHCPR programs.
Conclusion
In conclusion Mr. Chairman, the
health care marketplace continues to
change at a rapid rate, and timely and
accurate information from AHCPR-supported research is critical to
maintaining high quality health care
for all Americans.
Approval of AHCPR's budget
request for FY 1998 will ensure that
unbiased, reliable information on the
cost-effectiveness of treatments for
specific conditions, as well as
strategies to translate the best science
into routine practice, are
implemented and result in high-quality care at an affordable cost.
An investment in AHCPR's research
today can lead to cost savings in the
future. The results of our research
will help national, State, and local
policy makers to increase the value
of their expenditures on health care.
AHCPR's research has already lead
to reductions in costs for the
Medicare program.
