Testimony on Reauthorization of the Agency for Health Care Policy and Research

Supporting Policymakers with Data and Information

Policymakers need to understand how dramatic growth of managed care, changes in private health insurance, and other dynamics of today's market-driven health care delivery system have affected, and are likely to affect, the outcomes, quality of, cost of, and access to the health care that Americans use.

Developing and Improving Information Technology

Informatics is another tool for improving the quality of health care services. There has been an explosion in the use of information technology in medicine, such as telemedicine and computerized medical records. These technologies have greater potential to improve the quality of, outcomes of, access to, cost of, and use of care. To achieve this potential, we need research to determine what works and what doesn't work in "high tech" health care.

Informatics is an area of research that is critical to every aspect of AHCPR's work . Let me explain. First, the revolution in information technology is critical to the ability of health care delivery systems to measure and improve the quality of care that they provide their patients. They need seamless information systems—linking administrative, financial, and clinical data—that can follow patients no matter where or from whom they receive care. I am delighted to note that much of the pioneering work in developing the prototypes and evaluating their usefulness in daily practice was supported by our predecessor, the National Center for Health Services Research. AHCPR has an important and continuing role to play in evaluating the impact of informatics on the cost, access, and quality of clinical care and health care systems. Last year we funded eight projects to do just that [select for list of informatics projects].

Second, the type of research that AHCPR conducts and supports—to assess what works best in clinical practice and how we organize and manage the systems in which care is delivered—relies upon information technology at every step. The type of rapid analysis and dissemination of data on patient outcomes envisioned by some of the quality of care proposals under consideration by the Congress will not be possible if we do not advance the state of the technology and develop the common language that will let systems from various providers, plans, purchasers, and payers communicate with one another.

For both of these reasons, we have recently taken steps to integrate our informatics work into our other substantive research centers. This step will strengthen our commitment to informatics in the long run.

Because the Secretary believes that health informatics is critical issue to the health care system, she has asked me to co-chair the Department-wide Data Council, which will become an increasingly important forum for decisionmaking in the area of information technology and carrying out the Department's statutory responsibilities. AHCPR's experts in informatics will help the Data Council as it addresses issues of advancing a common language for information technology systems and addressing questions of their appropriate use.

AHCPR's Medical Expenditure Panel Survey (MEPS) provides policymakers and others with up-to-date, highly detailed information on how Americans as a whole, as well as different segments of the population, use and pay for health care. This ongoing survey also looks at insurance coverage and other factors related to access to health care. MEPS is the only survey that collects expenditure data from the non-Medicare population.

MEPS data is used by Congress and Federal agencies, including HCFA and other components of the Department of Health and Human Services, Office of Management and Budget, and Department of the Treasury. If MEPS data were available during my tenure on the Physician Payment Review Commission, it would have been an invaluable source of information in helping to make recommendations to Congress on payment for physicians.

These data also are used widely in the private sector by researchers at The Heritage Foundation, Lewin-VHI, Urban Institute, RAND Corporation, and Project Hope, as well as by health insurance companies, pharmaceutical firms, and other health-related businesses.

Using MEPS data on the first 6 months of 1996, AHCPR researchers Philip F. Cooper and Barbara Steinberg Schone have found that as many as 6 million Americans choose not to accept health insurance when offered it by their employers. The study found that the number of workers declining employment-based health insurance increased by 140 percent between 1987 and 1996 while the number of employers offering health insurance increased during those years. Those most likely to turn down insurance are young (under age 25), single, Hispanic or black, and work for low wages. Possible factors driving this trend include the decline in real wages, higher employee contribution rates, and State legislation aimed at enhancing insurance coverage which may have increased costs.

AHCPR's assistance is not limited to Federal policymakers. An important AHCPR program is the User Liaison Program (ULP), which plays a critical role in providing technical assistance to States and local policymakers on a wide range of issues. For example, the ULP program conducted a workshop geared toward State policymakers to examine the latest research findings on the uninsured and what State governments have been doing to solve the problem.

In 1998, the ULP will provide technical assistance to help State legislators and executive branch officials plan for and implement the State Children's Health Insurance Program (SCHIP) recently enacted by Congress.

One of AHCPR's statutory responsibilities is to conduct assessments of new technologies for the Medicare program (HCFA) and the Department of Defense. This information is invaluable to Federal policymakers and in some case drives coverage policy in the private sector. A case in point is AHCPR's technology assessment on lung volume reduction surgery (LVRS). This technology assessment concluded that there was insufficient evidence upon which to make a scientific judgment regarding the effectiveness of LVRS. AHCPR recommended that coverage be granted within the scope of a clinical trial, which is now being conducted by the National Institutes of Health. AHCPR is supporting the cost-effectiveness component of that trial. It is our hope that the collaborative efforts between the agencies will yield the information needed to make an informed coverage decision on LVRS.

AHCPR's new Evidence-based Practice Centers will continue to produce timely technology assessments that will assist Federal, State, and private sector decisionmakers make difficult coverage decisions.

Private-sector policymakers also use our research to make informed health care decisions. Recently, the Pharmaceutical Research and Manufacturers of America included AHCPR's research finding on atrial fibrillation to promote the use of blood thinning drugs in an advertisement touting "three ways pharmaceuticals are ganging up against health care costs."

AHCPR's research and data give policymakers the "big picture" on the cost, use, and access to health care in this country for them to use in making decisions about clinical policy, coverage, quality improvement, and spending.

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Conclusion

In order for health services research to fulfill its potential to improve the quality of the health care system, the foundation on which it rests must be strong. This foundation includes the tools that can be used to improve health care, the training to nurture and promote the best researchers, and the teams that foster partnerships and collaborations among the public and private sectors.

All of these elements will enable AHCPR to meet the challenges we face. Mr. Chairman and members of the Subcommittee, I respectfully request that you reauthorize AHCPR so that we can help our Nation's health care system by:

• Conducting and supporting research on the outcomes and effectiveness of treatments.
• Ensuring that clinicians, patients, health care system leaders, and policymakers have the information that will enhance quality of care.
• Identifying gaps in access to and use of health care services, achieving value for the Nation's health care dollar, and helping the market find ways to fill those gaps.

These issues are critical to a sound, high quality health care system. I look forward to working with the Subcommittee in the months ahead to find ways to improve health care decisionmaking.

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Additional Information

Evidence-based Practice Center Topics

1. Pharmacotherapy for alcohol dependence: Research Triangle Institute and University of North Carolina at Chapel Hill, NC.
2. Management of stable angina: University of California, San Francisco, CA, and Stanford University, Stanford, CA.
3. Diagnosis of sleep apnea: MetaWorks, Inc., Boston, MA.
4. Treatment of attention deficit/hyperactivity disorder: McMaster University, Hamilton, Ontario, Canada.
5. Rehabilitation of persons with traumatic brain injury: Oregon Health Sciences University, Portland, OR.
6. Testosterone suppression treatment for prostatic cancer: BlueCross and BlueShield Association Technical Evaluation Center (TEC), Chicago, IL.
7. Evaluation of cervical cytology: Duke University, Durham, NC.
8. Depression treatment with new drugs: University of Texas, San Antonio, TX.
9. Evaluation and treatment of new onset of atrial fibrillation in the elderly: Johns Hopkins University, Baltimore, MD.
10. Prevention and management of urinary complications in paralyzed persons: RAND Corporation, Santa Monica, CA.
11. Diagnosis and treatment of acute sinusitis: New England Medical Center, Boston, MA.
12. Diagnosis and treatment of dysphagia/swallowing problems in the elderly: ECRI, Plymouth Meeting, PA.

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Informatics Studies

• Research at the University of North Carolina will modify an existing reminder system. The Child Health Improvement Program to facilitate its use in primary pediatric practices.
• Research at Children's Hospital in Boston will address the problem of jaundice in infants by developing and implementing a computer-based decision support system. This system will help providers identify and treat infants at risk for developing significant medical problems associated with jaundice by providing better access to patient records and guidelines.
• Research at the University of Pittsburgh will develop and implement a computerized decision-support system that prompts primary care physicians to implement treatment recommendations based upon the AHCPR-sponsored research on depression in primary care. Following this, the researchers will conduct a randomized clinical trial to examine the clinical outcomes and costs of providing care this way, and will evaluate the effects on physicians' practices, knowledge and attitudes of disseminating the depression guideline by computer.
• Research at Duke University will study the increased use of guideline recommendations by automating clinicians' access to a decision support system that makes relevant guidelines available at the point of care through an interface with electronic medical record systems. This study will create a clinical decision- support system that uses a World Wide Web-based guideline server. The server is directly accessible from electronic medical records systems and protects patient confidentiality.
• Research at the Fred Hutchinson Cancer Research Center in Seattle, WA, will look at improving primary care physicians' abilities to manage post-discharge bone marrow transplantation patients by developing, implementing and evaluating a World Wide Web-based computerized decision-support system. The intent is to facilitate information exchange among physicians in different locations and experts in bone marrow transplantation centers.
• Research at the Medical College of Georgia will study the efficacy of telemedicine colposcopy, delivered by rural primary care practitioners. Given the disproportionate prevalence of cervical malignancies in minority, poor, rural women, this study will recruit over 200 individuals from two rural sites and transmit their colposcopy images to the Medical College of Georgia via an existing telemedicine system to provide easily accessible, expert colposcopic diagnostic services.
• Research at University of Indiana's Regenstrief Institute will use patient reports and evaluations of care to drive a computer-based improvement intervention targeted toward providers in a municipal teaching hospital and determine by a randomized controlled trial whether this intervention leads to improved patient outcomes.
• Research at Barnes Jewish Hospital in St. Louis, MO will implement and evaluate two computerized drug monitoring systems—DoseChecker and ADE Monitor—and design and implement a drug alert notification subsystem in different clinical settings within the Washington University and Barnes Jewish Hospital health system. The alert notification subsystem will be evaluated for differences in expert system performance, physician acceptance and clinical impact.

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Current as of February 1998