2.1.2 Performance Goal 2: To develop the evidence base for policymakers and health systems to use in making decisions about what services to pay for, how to structure those services, and how those services are accessed.

Program Description and Context

Adequate access to health care services continues to be a challenge for many Americans.  This is particularly true for the poor, the uninsured, and members of minority groups, and rural residents.  In addition, the changing organization and financing of care has raised new questions about access to a range of health services including emergency and specialty care.  At the same time examples of inappropriate care, including over utilization and misuse of services, continue to be documented.  Through ongoing development of nationally representative and more specialized databases, the production of public-use data products, and research and analyses conducted by AHRQ staff, the Agency addresses critical policy issues pertaining to the access, cost and use of health care.

Research related to the effects of payment and organizational structures and processes on the cost, quality and equity of health care services are essential components of this research initiative.  Research results are intended to:

1. Improve clinical practice.
2. Improve the health care system's ability to provide access to and deliver high quality, high-value health care.
3. Provide policymakers with the ability to assess the impact of payment and organizational changes on outcomes, quality, access, cost, and use of health care services.

Responding to the IOM report, Crossing the Quality Chasm, AHRQ will fund applications that provide rigorous, objective, and essential evidence required by public and private decisionmakers seeking to understand and improve the health care system, to make changes in health care delivery, insurance, and financing, and to manage the system in a manner that would induce efficient, effective, equitable, accessible and timely health care.

Important issues to be addressed by such research include:

1. How do different payment methodologies and financial incentives within the health care system affect health care quality, costs, and access? 
   1. How do payment methodologies affect the behavior of health care organizations and individual providers? 
   2. Which payment arrangements among patients, providers, and health plans enhance patient-centered knowledge of and involvement with treatment regimens? 
   3. How do payment policies affect decisions about the purchase and selection of health services and health insurance? 
   4. What is the role of quality in such decisions? 
   5. What are the effects of such decisions on health care costs? 
2. What has been the impact of purchaser and public sector initiatives on quality, costs, and access to health care and health insurance?  Of particular interest is the impact of employer and coalition efforts on the quality and cost-effectiveness of care in the marketplace, the impact of State efforts to monitor and improve access and quality and the impact of public and private payment changes on access to health care and to health insurance for vulnerable populations. 
3. What organizational structures and processes are most likely to sustain high-quality, efficient, effective, timely, and accessible health care?
4. How do different patterns and levels of market competition affect the quality and cost of care?

In addition, AHRQ will fund projects in basic methodological work to support such research, including: development of payment methodologies; improvements in analytical and empirical methods required to simultaneously address issues of efficiency, quality, and equity; and, improvement in data collection methods and qualitative methods needed to understand the structure of new health care organizations and an evolving health care system. 

Strategies to Improve Access, Foster Appropriate Use and Reduce Unnecessary Expenditures

Excellence Centers to Eliminate Ethnic/Racial Disparities. The health of Americans has improved over the past few decades, but not all Americans have benefited equally.  Many ethnic and racial groups have not shared in the advances in health outcomes and health care.  To understand the causes and factors of these inequalities, AHRQ in September 2000 awarded grants to nine centers to conduct a series of related studies.  Now known as Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED), the grants bring together teams of both new and experienced investigators in a five-year effort to analyze underlying causes and contributing factors for racial and ethnic disparities in health care and to identify and implement strategies for reducing and eliminating them.  The centers of excellence approach enables an assembly of a critical mass of investigators to address a group of projects linked by a central theme, such as communication or cultural competency.  In addition, the centers are able to train new investigators with an interest in minority health services research.

The EXCEED program joins a series of AHRQ initiatives aimed at improving the health and health care of priority populations and eliminating racial and ethnic disparities in health outcomes and in health care access and service delivery.  AHRQ expects that lessons learned from understanding and eliminating racial and ethnic disparities in health and health care as well as the practical tools and strategies to eliminate these disparities would be generalizable beyond the communities studied.  By focusing on the attributes of the ethnic and racial groups, the underlying etiologies for the disparities, and components and conditions of interventions to eliminate the disparities, these projects should produce findings that are widely applicable for minority as well as majority populations across the county.

Integrated Delivery System Research Networks. The Integrated Delivery System Research Networks (IDSRN) is a new model of field-based research that links the Nation's top researchers with some of the largest health care systems to conduct research on cutting edge issues in health care on an accelerated timetable.

The IDSRN was developed explicitly by AHRQ to capitalize on the research capacity of, and research opportunities occurring within, integrated delivery systems.  The network creates, supports, and disseminates scientific evidence about what works and what does not regarding measurement systems and organizational "best practices" related to care delivery and research diffusion.  It also provides a cadre of delivery-affiliated researchers and sites to test ways to adapt and apply existing knowledge.

As a group, the IDSRN provides health services in a wide variety of organizational care settings to over 34 million Americans, including the privately insured, Medicare and Medicaid patients, the uninsured, ethnic and racial minorities, and rural and inner-city residents.  Moreover, each of the nine IDSRN partners have the following three unique attributes that make it particularly well suited for conducting time-sensitive research:

• Available Data: each of the IDSRN partners collect and maintain administrative, claims, encounter and other data on large populations that are clinically, demographically and geographically diverse.
• Research Experience: IDSRN partners include some of the country's leading health services researchers with expertise in quantitative and qualitative methodologies as well as first hand knowledge of emerging issue areas which have critical policy or managerial implications.
• Management authority to implement health care interventions: IDSRN partners have responsibility for managing delivery systems and are in a position to implement financial and organizations strategies, e.g., selective contracting with physicians and hospitals for specific approaches to diffuse clinical guidelines within the system.

Primary Care Based Research Networks. Over the past decade, Primary Care Based Research Networks (PBRNs) have emerged as a promising approach to the scientific study of primary care.  A PBRN is a group of ambulatory practices devoted principally to the primary care of patients, affiliated with each other, and often with an academic or professional organization, in order to investigate questions related to community-based practice. Typically, PBRNs draw on the experience and insight of practicing clinicians to identify and frame research questions whose answers can improve the practice of primary care.  By linking these questions with rigorous research methods, the PBRN can produce research findings that are immediately relevant to the clinician and, in theory, more easily assimilated into everyday practice.  In addition, data is readily available which will provide useful information on who receives care, where and how often.

In September 2001, 18 PBRN networks were awarded continuation grants (cooperative agreements) to conduct network-defining surveys, using standardized instruments. The surveys will provide baseline data on the clinicians enrolled in each network, the services provided, and the characteristics of patients receiving those services.  Potential uses of the data include practice benchmarking and guiding the selection and design of specific PBRN research projects.  Four of the networks were awarded additional funds to pilot test and evaluate electronic methods of collecting and aggregating practice-derived research data.  Two networks were awarded additional funds to assess clinician and patient knowledge and attitudes about protecting the privacy and confidentiality of research data.

AHRQ's overall goal is to improve the capacity of PBRNs to expand the primary care knowledge base and to establish mechanisms that will assure that new knowledge is incorporated into actual practice and its impact is assessed.

HIV Research Network. As new HIV/AIDS therapies become available, policymakers require reliable information about the type and costs of the health care services persons with HIV disease are receiving—such that informed resource-allocation decisions can be made.  The HIV Cost and Services Utilization Study (HCSUS) is the first major research effort to collect information on a nationally representative sample of people receiving HIV care.  HCSUS is examining costs of care, utilization of services, access to care, quality of care, quality of life, unmet needs for medical and non-medical services, social support, satisfaction with medical care, and knowledge of HIV therapies.

HCSUS is composed of a core study and several supplemental studies. The core study has enrolled a national sample of 2,864 HIV-infected adults who were receiving ongoing or regular medical care in the first 2 months of 1996.  Respondents were sampled from 28 urban areas and 24 clusters of rural counties in the United States.  Patients receiving services in hospitals, clinics, and private practice settings were enrolled.  HCSUS over-sampled women and members of staff model health maintenance organizations to obtain more precise information on these specific populations.  Supplemental studies are examining HIV care delivery in rural areas, prevalence of mental and substance abuse disorders, oral health of HIV-positive individuals, and issues related to HIV-infected persons over 50 years of age. A consortium of private and government institutions are conducting HCSUS. Local and national advisory groups have been established to facilitate communication between the HIV community and the research consortium.

The HIV Network goal is to provide timely and relevant information to policymakers about the resources utilized to treat persons with HIV.  It is important to obtain timely data because quickly occurring therapeutic advances, the shifting epidemiology of HIV infection, and the rapid diffusion of managed care are having a major effect on patterns of health care resource utilization for HIV.  Nearly $9 billion was spent in 2002 by Medicaid, Medicare, the Department of Veterans Affairs, and the Ryan White CARE Act to treat those with HIV.

Healthcare Cost and Utilization Project. The unprecedented volume and pace of change in the U.S. health care system and the non-uniform changes that are occurring across the country require a new information paradigm that is scientifically sound for use at the national, regional, and State levels.

The Healthcare Cost and Utilization Project (HCUP) is a Federal-State-industry partnership to build a standardized, multi-State health data system that is made available to the public.  Maintained by AHRQ, HCUP comprises a family of administrative longitudinal databases—including State-specific hospital-discharge databases and a national sample of discharges from community hospitals—and powerful, user-friendly software that can be used with both HCUP data and with other administrative databases.

HCUP databases fill a unique niche and are increasingly being tapped by analysts and researchers interested in hospital utilization, access, charges, quality, and outcomes. The data are used to:

• Describe patterns of care for uncommon as well as common diseases.
• Analyze hospital procedures.
• Study the care of population subgroups such as minorities, children, women, and the uninsured.

 

Researchers and policymakers use HCUP data to identify, track, analyze, and compare trends at the national, regional, and State levels.

FY 2004 performance goals and targets

Performance Goal	FY 2004 Targets
Increase the number of partners contributing data to the HCUP databases by 5% above FY2000 baseline.	5% increase over FY00 baseline.

2.1.3 Performance Goal 3: To build the capacity for improving the Quality of Health Care Delivery through Research and Training

Program Description and Context

Today's health environment continues to change rapidly.  Consolidation of health plans, movement of patients and providers into managed care settings, efforts to contain rising health care costs, fears that cost containment measures will lower the quality of care, and persistent problems in access to care and health insurance coverage for many Americans are issues of great concern. 

Public and private purchasers are experimenting with new, untested financing strategies, organizational arrangements and delivery approaches.  Health plans and providers are seeking to measure and improve the effectiveness and cost-effectiveness of the care they purchase or provide.

Decisionmakers at all levels in the health care system rely on this critical knowledge to inform effective choices.  For example:

• Purchasers are looking for value, for high-quality care at a reasonable cost.
• Patients and caregivers want to make informed decisions about preventive and other primary care services, treatments, providers, and health care plans.
• Clinicians need information to make the best possible decisions for and with their patients.
• Health plans need information to determine which services to cover.
• Institutional providers (hospitals, groups, systems of care, et al.) need information to make decisions.
• Policymakers need to understand the ramifications of available policy options.

Health services research addresses these issues by providing information to help people make decisions at the clinical, system and policy levels.  Ensuring this requires an adequate number of highly qualified research scholars.  AHRQ therefore continues its commitment to support the education of future research leaders through a variety of research and institutional training programs.

Strategies to Improve the Quality of Health Care Delivery through Research and Training

National Research Service Awards. AHRQ supports 24 U.S. academic institutions that offer advanced health services research training.  These programs provide tuition support and stipends to qualified pre-doctoral and postdoctoral students.

Dissertation Research Grants. Dissertation research funding is available for students conducting doctoral-level research on some aspect of the health care system.  These grant awards are often the first step toward establishing a career in health services research.

Career Development Awards. AHRQ began to support career development activities in FY 2000.  These awards, provided to individuals embarking on a research career, allow individuals time and resources to gain experience in carrying out actual research.  The intent is to provide transitional support for newly-trained investigators in order to launch them on research careers.  This program supports two career development programs:

• Mentored Clinical Scientist Development Award (K08) in Health Services Research.  This research award provides support for the development of outstanding clinician research scientists with a focus on development as an independent scientist.
• Independent Scientist Award (K02) in Health Services Research.   The K02 provides support for newly-independent investigators with a clinical or research doctoral degree.

Minority Research Infrastructure Support Program. AHRQ is committed to the Department's Initiative to Eliminate Racial and Ethnic Disparities in Health and the complementary Healthy People 2010 Goal to eliminate disparities in health.  A critical component in achieving these goals is to expand the Nation's health workforce to be more diverse and representative of the racial and ethnic populations.

In FY 2001, AHRQ launched the Minority Research Infrastructure Support Program (M-RISP).  The goals of the M-RISP program are to increase the number of minority health services researchers and to build capacity for institutions to conduct health services research intended to improve health for racial and ethnic minorities. 

Building Research Infrastructure & Capacity Program (BRIC). In order to build research capacity in States that have not traditionally been involved in health service research, the Building Research Infrastructure & Capacity Program (BRIC), funds four two-year planning grants to pilot test the feasibility of developing a new program to broaden the geographic distribution of AHRQ funding and enhance the competitiveness for research funding of institutions located in States that have a low success rate for grant applications from AHRQ.  These grants will stimulate sustainable improvements in capacity and/or multi-disciplinary centers supporting investigators and multiple research projects with a thematic focus.

Program Performance Analysis

Developing the Evidence Base for Policymakers and Health Systems To Use in Making Decisions about What Services To Pay for, How to Structure Those Services, and How those Services Are Accessed.

Women with Pelvic Inflammatory Disease Treated as Outpatients Have Long-term Outcomes Comparable to Those Treated as Inpatients. Women with mild to moderate pelvic inflammatory disease (PID)—a leading cause of infertility—who are treated as outpatients have recovery and reproductive outcomes similar to those for women treated in hospitals.  Each year, about 1.2 million women are treated for PID, a sexually transmitted disease that causes infection and inflammation of all or some of the pelvic organs. Untreated, it can cause chronic pelvic pain, ectopic pregnancy, and infertility.  Over 100,000 women with PID are hospitalized each year, and about 15 percent of them have acute and serious versions of the disease that require intensive inpatient treatment.  But for approximately 85,000 women with mild or moderate PID, who currently are being hospitalized, treating them as outpatients may save approximately $500 million each year.

New Case Study Indicates that Mental Health Parity Did Not Raise Costs for a Large Employer Who Used a Managed Care Arrangement. Using a managed care "carve-out" arrangement to provide equal coverage for mental health services did not raise costs for one large employer.  Researchers examined the impact of a State's mental health parity mandate on a large employer group that simultaneously implemented a managed care "carve-out" for its mental health and substance abuse benefits.  Carve-outs are services provided within a standard health benefit package but delivered and managed by a separate organization.  The researchers, compared plan costs, use patterns and access in the one year prior to the changes with the three years following the changes.

Although the number of people treated for mental health problems increased nearly 50 percent, the costs to the plan for mental health services declined by almost 40 percent over the four-year study period.  Costs for employees and spouses together remained flat over the study period while costs for children and adolescents declined by 64 percent.  Most of this decline was due to reducing the lengths of stay for inpatient mental health treatment.  Managed care did not limit access to outpatient treatment; there was nearly a 50 percent increase in the number of people using outpatient treatment with no change in the average number of visits.

Black and Hispanic HIV Patients Are Less Likely to Get Experimental Medications. A Nationwide study sponsored by AHRQ showed that black and Hispanic HIV patients are only about half as likely as non-Hispanic whites to participate in clinical trials of new medications designed to slow the progression of the disease.  Together, blacks and Hispanics comprise roughly 48 percent of the HIV patient population: 33 percent and 15 percent respectively.

Black and Hispanic patients' limited attempts to obtain experimental HIV medications may reflect lack of awareness of clinical trials in minority communities, as well as suspicion and distrust of trials and researchers.  Black patients were less than half as likely as white non-Hispanic patients to try to obtain an experimental HIV medication.  Findings suggest that to boost minority participation in trials, structural barriers such as research-entry criteria, enrollment and tracking procedures, and study center operations, as well as clinical researchers' attitudes and practices need to be examined.  Other factors contributing to a reduced likelihood of participation in a clinical trial were having less than a high school education, being in a commercial HMO, and receiving primary care eight miles or more from where the clinical trial was held.

FY 2004 performance goals and targets

Performance Goal	FY 2004 Targets
Increase the number of minority researchers trained as health services researchers by 5% annually.	5% increase over FY 2003 baseline.
Support training programs for junior-level researchers and mid-career scientists.	Maintain baseline.

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