New discoveries are the lifeblood of medical progress, but they don’t do any good until they are actually used to treat illness and save lives. That’s why I’m troubled by plans to cut the budget of the federal Agency for Healthcare Research and Quality (AHRQ) or eliminate it altogether. Undermining this essential organization will create serious problems for patients, care providers, and the entire health care system.
Though AHRQ is a little-known part of the US Department of Health and Human Services, it’s a small organization with a big job: helping translate discoveries and best practices into everyday clinical care. Its grants and programs support the health services researchers who in effect act as the physicians for our complex $3 trillion health care system by diagnosing what’s working well and what isn’t, then prescribing needed changes. Our health is at stake as a result of that work, just as the health of an individual patient can depend on the prescriptions written by his or her doctor.
Take cancer care as an example. Back in the mid-1990s, when I was writing a book about the quality of American medicine, I was shocked to discover through the health services research literature that treatment guidelines regularly sent to doctors by the National Cancer Institute (NCI) had virtually no effect on medical practice.
Two decades later, NCI-designated Comprehensive Cancer Centers that follow evidence-based guidelines are quietly saving lives. A 2015 study, for example, found that women with ovarian cancer had a nearly 20 percent higher survival rate at centers following the guidelines than women treated at high-volume hospitals that hadn’t earned the NCI’s designation. If a new drug showed that level of effectiveness, it would be page one news.
What’s true in cancer treatment also holds for diabetes, heart disease, and a host of other conditions. New evidence is not magically whisked into the exam room. It takes work to translate important findings into practice, and even more to persuade doctors to adopt them.
Unfortunately, research that points out medical practice shortcomings — even if it also suggests viable solutions — is much less politically attractive than lavishing funds on promised cures. Moreover, fact-based guidance that punctures policy proposals promising to painlessly cure our health system’s ills is particularly unpopular among those who prefer to follow their ideological instincts.
Back in 2006, for example, a colleague and I wrote a scholarly article disputing the assertion that medical costs were causing a cascade of individual bankruptcies and single-payer health insurance would stop them. Liberals howled, while conservatives gleefully used our article a few years later to tar one of the coauthors of an influential article on medical bankruptcy, a Harvard law professor named Elizabeth Warren who had gone on to more prominent pursuits. Conservatives, for their part, tend to ignore evidence that making individuals dig ever deeper into their wallets with high-deductible health insurance creates not savvy shoppers but anxious patients who skip both needed and unneeded care.
There have been some attempts in recent years to highlight AHRQ’s importance to a public and press primed to focus on a steady stream of proclaimed medical “breakthroughs.” But the attacks against it have gotten stronger. Republicans almost killed AHRQ’s predecessor agency in the 1990s after Texas spine surgeons took exception to agency guidelines suggesting spine surgery was often performed unnecessarily. The agency survived, with a slashed budget, by changing its name and modifying its mission. More recently, Republicans in the House tried to ax the agency again starting in 2012 and almost succeeded in 2015 despite protestations by conservative researchers that there’s nothing un-conservative about examining what’s wasteful and what’s not.
The agency’s survival may mostly be due to legislative gridlock, as continuing budget resolutions have kept the government going with only minor changes. Still, a few weeks ago, a Senate appropriations subcommittee allocated AHRQ just $324 million for fiscal 2017, a cut of $40 million in two years. The allocation is under 1 percent of the $34 billion budget approved for the NIH.
That ovarian cancer study I mentioned? Fewer than 1 in 4 of the cancer centers in the study implemented all of the evidence-based guidelines. There’s no question that the doctors who treated the women in this study were sincerely trying to “do their best.” But the women who unnecessarily died as a consequence of a profession that too often resists any guidance were just as dead as if effective treatments had never been found. Health services research points out this and other unpleasant truths, but it also points out ways we can fix those flaws and save lives. That why I and so many colleagues remain passionate about pursuing this type of work.
According to AcademyHealth, the professional society for the field, slashing or eliminating funding for AHRQ “reduces our capacity to ensure patient safety, address waste and inefficiency, and ensure access to groundbreaking treatments and prevention.” I call it just plain dangerous.
Perhaps Senator Warren can persuade her colleagues that the type of research supported by AHRQ may sometimes burst one’s personal ideological bubble, but it is good for their constituents and for the country.
Michael L. Millenson is president of Health Quality Advisors LLC in Highland Park, Ill., an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine, and author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age.”