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STATEMENT OF THE Introduction Mr. Chairman, I want to thank you and the distinguished members of the Senate Labor and Human Resources Subcommittee on Public Health and Safety for the opportunity to appear before you today to address issues related to Public Expectations and Health Care Quality: Role of AHRQ. I am Dr. David Kindig, Professor of Preventive Medicine and Health Policy, University of Wisconsin at Madison, and President of the Association for Health Services Research (AHSR). It is in my capacity as President of AHSR that I appear before you today. The Association for Health Services Research is a non-profit organization and the only national membership association formed exclusively to promote the field of health services research and to strengthen the relationship between the users and producers of health services research. The organization’s primary mission is to increase the contribution that health services research makes to improve the health care system and health status of Americans. A key priority of AHSR is to improve the development and use of high quality public and private data and information systems, and research methods and tools. AHSR has more than 2,800 individual members and approximately 140 organizational members. Our membership reflects the field’s breadth and scope and includes researchers, clinicians, policymakers and managers in a variety of employment settings including universities, foundations, health delivery, health industry and government. Our testimony today focuses on three main points:
AHRQ Reauthorization In the continuum of health research, health services research begins where biomedical research ends. Biomedical research focuses on issues related to causes and treatment of disease. Health services research and much of AHRQ’s work focuses on issues related to cost, quality, and use of health services at both individual and organizational levels. We applaud the growing support for scientific advances in health, but we must also recognize that advances made in biomedical science are incomplete without scientific cost and quality research and evaluation that comes from health services research and agencies such as AHRQ. The need for health services research to complement biomedical discoveries, by successfully assuring their adoption by individuals and organizations delivering care, will become even more critical in future decades as health resources are further constrained. AHSR worked closely with Congress and the Bush Administration in developing the Agency’s original authorization statute, and we are pleased to support your efforts to develop reauthorization legislation. The focus of today’s hearing is on quality of care. I want to emphasize, however, that AHRQ’s mission must contain a balanced portfolio of research in all areas of cost, organization, access, and quality. We believe that this breadth is well-reflected in the current general authority for the Agency. Under current authority, the Agency conducts and supports research, demonstration projects, evaluations, training, guideline development, and the dissemination of information on health care services and on systems for the delivery of services, including activities with respect to:
AHRQ’s current work in these areas is particularly important as public and private policymakers respond to a constantly changing health care environment. In testimony before the Medicare Commission last week, Alan Greenspan, Chairman of the Federal Reserve Board, stressed that we do not know for certain how advances in medical technology influence the cost or quality of health care. Is Chairman Greenspan right? Do we know what returns we are receiving from our investment in health care? Health services research can answer these fundamentally important questions and AHRQ can lead the way. AHRQ Role in Quality AHRQ and the health services research it supports are critically important to any health care quality initiative. The American public strongly supports funding for health services research into quality of care issues as evidenced by a recent six state (CT, MI, MO, VA, WA, WV) survey by Research!America. An average of 88 percent of respondents in these six states said health services research into quality of care and outcomes for patients was valuable. Growing public concern about health care quality is largely tied to managed care growth and public dissatisfaction with managed care. In response to these concerns, several health care quality initiatives are currently before Congress. The Health Care Quality, Education, Security and Trust Act, which was recently introduced by Senators Jeffords and Lieberman and referred to this committee, is an important example of congressional focus on the need for a federal commitment to quality health care. This legislation cites four findings that are widely supported and will ultimately guide development of any health care quality legislation passed by Congress. These four key findings are:
Addressing the needs arising from these findings is currently an important part of AHRQ’s mission. Our nation’s health care has benefited greatly from the Agency’s ongoing efforts to generate and disseminate research and information that enhances quality improvement. AHRQ has a particularly strong record of public-private partnerships in various quality improvement initiatives. No other Federal agency is focused on each of these critical issues across the broad array of health care delivery problems. AHRQ has the internal expertise to coordinate Federal quality efforts and has a strong track record under its current mandate. Some examples are:
AHRQ has a wide array of ongoing initiatives that generate and disseminate important research and information to improve health care quality. Under the Jeffords bill, AHRQ would be responsible for collection, analysis and dissemination of health care quality information in the areas of quality benchmarks, quality indicators and outcome measures, and national report cards on the state of our nation’s health. Similarly, the Administration has proposed a quality initiative that facilitates consumers’ use of information on quality, strengthens value-based purchasing by the Department of Health and Human Services (DHHS), improves the quality of health care services delivered directly by DHHS programs, expands research that improves quality and measures national health care quality. If Congress is to achieve its goals with quality initiative legislation, reauthorization of AHRQ must be fundamentally consistent with and supportive of such quality initiative goals. With or without the Health Quality Council called for in the Jeffords bill, or similar legislation, Congress will need to designate a lead agency to provide the scientific support critically necessary to the success of any health care quality initiative. AHRQ should be the agency and legislation reauthorizing AHRQ should be developed with this in mind. While strongly supporting reauthorization of AHRQ and expanding its role, I would like to urge this Subcommittee to be very cautious about granting the Agency regulatory powers or powers that are perceived to be regulatory. This was an important lesson learned from the backlash against AHRQ’s practice guidelines a few years ago. Quite simply, granting regulatory authority to AHRQ could undermine public support for the Agency’s scientific work. AHRQ’s primary role with respect to health care quality is and must be to support science-based research and to assist the public and private sector in translating that research into practice and ultimately into quality improvement. In addition, I believe that AHRQ can provide a stronger lead role within DHHS in supporting HCFA’s technology assessment activities, evaluating the effectiveness of Medicare and Medicaid and their demonstrations, and coordinating health statistics and data with health services research and the health care quality initiative. Resources for AHRQ Mr. Chairman, in addition to reauthorizing the programmatic aspects of the Agency’s mission, there is a critical need to provide the funding support to carry out these functions. This is particularly important in terms of any expanded role for the Agency in providing scientific support for a national health care quality initiative. Appropriations for AHRQ have not even kept up with inflation over the past five years. In 1997, the success rate for an investigator-initiated grant was 3.4 percent at AHRQ as compared to 28 percent at NIH. With all due respect, Mr. Chairman, with those odds, would you apply? If the agency’s funding continues to stagnate so will our field; the promise of health services research will not be fully realized; and the hopes of the congress and the American people for the highest possible quality of care will not be achieved. We applaud and support the approach that all three federal science agencies, NIH, CDC and AHRQ will require increased support in the near future, if the nation is to have a cost effective and high quality health care system Our nation’s economic health is better than it has been for more than three decades – economic growth is steady, inflation is low, government deficits are at nearly all-time lows for the post-war period. Even more important, and independent of the business cycle, is the production and support of new knowledge, which is a classic example of a true public good. This is not an activity about which one can say, "if the federal government does not do it, the private sector and perhaps state and local government will step in." Ultimately, lack of federal support for AHRQ will undermine any congressional effort to improve the quality of health care Americans receive. AHSR recommends that the activities envisioned for an expanded role for AHRQ be supported by an annual funding level of $500 million by the year 2003. This would represent less than 5/100 of 1 percent of national health expenditures, a very small investment to improve the quality and cost-effectiveness of our health care system. Conclusion Mr. Chairman, I have testified today on the need for reauthorizing AHRQ, the role the Agency can play in supporting expanded health care quality initiatives and the resources required for the Agency to carry out these initiatives. It is critically important that AHRQ be reauthorized and sufficiently funded to support these initiatives. Doing so will go a long way towards establishing AHRQ as the international leader in quality and cost-effectiveness research, similar to the standard NIH sets in biomedical research. Most importantly, we can make major strides in assuring continuous quality improvement of the health care received by Americans. Again, thank you for the opportunity to appear before you today. I look forward to working with you and members of the Subcommittee during this important process and will be pleased to respond to any questions regarding my testimony.
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