A little-known federal agency responsible for making health care safer and more efficient has survived 20 years in Washington with a target on its back, but its time may be running out.
The Agency for Healthcare Research and Quality has made enemies because it takes a hard look at whether popular — and often expensive — treatments like spinal surgery actually help patients.
Supporters say it plays a key role in controlling health care costs and ensuring that medical practice is dictated by evidence, not the financial interests of doctors and insurers in a $3.4 trillion industry.
“American health care can’t thrive without the lights on,” said Dr. Donald Berwick, former director of the Centers for Medicare and Medicaid Services under President Obama. “We need to know what’s happening.”
But Republicans have long dismissed the agency as duplicative and wasteful.
Now, President Trump is proposing to eliminate the agency’s independent status and merge it with the National Institutes of Health — which also faces huge funding cuts under the administration’s proposed budgets.
“Clearly, some of the kinds of things that are being done at NIH are also being done at AHRQ,” Health and Human Services Secretary Tom Price said in a budget hearing on Wednesday. He said the proposed changes would improve efficiency “but also make sure we’re continuing to fulfill [AHRQ’s] mission.”
AHRQ, whose roots date back to 1989, generates reams of data used to examine the effectiveness of health care practices. Its signature initiatives include helping identify ways to reduce medical errors and curbing hospital-acquired infections that kill tens of thousands of people each year. The agency has an annual budget of $334 million, following an 8 percent cut in the final year of the Obama administration.
Focusing on applied research
Even staunch supporters of AHRQ don’t see malice in the efforts to cut its funding. They see a misunderstanding of its role.
AHRQ is focused on applied research: examining the effectiveness and costs of clinical practices, and how they impact different populations. It is involved in some of the most pressing questions in medicine: how to change prescribing of opioids, improve care for diabetics, use telehealth to serve rural patients, and prevent medication mistakes and infections. It is also investigating how to better prepare patients to leave the hospital to avoid costly readmissions.
“When you think about how many taxpayer dollars are spent to pay for health care under any scenario — Medicare, Medicaid, CHIP — to not invest a tiny amount of money to understand how to improve the quality of care seems so ill-advised and shortsighted,” said Lisa Simpson, chief executive of Academy Health, a health care research organization.
Simpson, who previously served as a deputy director of AHRQ, said she has used the agency’s data on health care costs and utilization to examine out-of-pocket costs for child mental health services, orthodontic care, and re-hospitalization rates, among many other research projects. “When so much is changing, it is critical for us to understand for whom and for which communities these changes result in improvement, and for which they are actually harmful,” Simpson said.
In some ways, she said, AHRQ has suffered from a lack of visibility. Although its research on cost and quality is widely used within the scientific community, it remains somewhat obscure compared to larger agencies such as the Centers for Disease Control and Prevention, the NIH, and the new Centers for Medicare and Medicaid Services Innovation Center, which was given a $1 billion budget during the Obama administration to test changes in the delivering and financing of medical care.
All of that has made it easier for Congress chop AHRQ’s budget.
In fiscal year 2016, Oklahoma Representative Tom Cole became the third consecutive GOP chairman of the committee overseeing health appropriations to recommend the elimination of its funding. Cole proposed to incorporate some of its programs in other agencies. The Senate initially proposed a 35 percent cut, but the agency won support from the White House, and survived with an 8 percent cut.
“That was seen as a big triumph,” said Dr. Richard Kronick, the agency’s director at the time, who is now at the University of California, San Diego.
A major effort to reduce infections
As proof of the agency’s unique role, Kronick pointed to its effort to curb hospital-acquired conditions, such as deadly bloodstream infections.
Data about that effort was plastered across the agency’s home page last week: Since 2010, it says, AHRQ’s research and tools for providers have helped to produce a 21 percent reduction in hospital-acquired conditions, translating to 3 million fewer adverse medical events and savings of $28 billion.
“It resulted in 124,000 fewer people dying in hospitals because hospitals are safer places than they used to be,” Kronick said. “We don’t know exactly why that 21 percent decline occurred, but there is good reason to think it’s because of the production of evidence about how to make health care safer, the production of tools and training materials to make sure that the evidence is understood and used, and the support for data systems that produce valid measures of progress.”
AHRQ’s effort to reduce hospital-acquired conditions has taken many forms. It has published tool kits to help hospitals prevent bed sores, falls, urinary tract infections, and medication mistakes. It has also funded research to help reduce infections in catheters inserted into patients to deliver nutrients and medicine.
Dr. Peter Pronovost, a Johns Hopkins University physician funded by AHRQ, developed an infection prevention checklist in 2001 for intensive care providers, including hand-washing and wearing protective clothing, such as gowns, gloves, and sterile masks. He said the money from AHRQ helped to disseminate the checklist and other prevention tips to providers across the country.
Since then, those infections have dropped by as much as 80 percent in intensive care units in the US, according to a 2013 study.
“These infections were a public health problem on par with breast and prostate cancer,” said Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins. “Imagine the praises we’d be singing if someone knocked prostate cancer down by that much. We certainly wouldn’t be saying, ‘Let’s defund the agency that helped make that real.’”
While such work generates bipartisan support, AHRQ is also situated at the sensitive crossroads of science and health care reform, where political agendas blur the lines between evidence and innuendo, often causing otherwise straightforward research to become controversial.
The agency found itself in the middle of a fierce battle when it looked at treatments for lower-back pain in the 1990s. It issued guidelines that said, in most cases, less invasive interventions would eventually cause the pain to go away without the need for costly operations.
While adopted by large segments of the medical community, the findings generated howls of protests from the North American Spine Society, whose members received a large share of the money spent on back surgery. They complained to Republican budget leaders, who then concluded that the agency’s work was inefficient and duplicative, and proposed to eliminate its funding.
In that battle, AHRQ lost a quarter of its funding and ended up changing its focus and name (it was formerly the Agency for Health Care Policy and Research). Simpson, the Academy Health CEO who worked at the agency during the transition, said its leadership resolved to move away from publishing specific guidelines.
For several years, the agency managed to stay out of Congress’s crosshairs — that is, until the next round of health care reform arose under President Obama. The Affordable Care Act increased financial pressure on clinicians to deploy evidence-based practices and reduce health care spending; it also reassigned AHRQ’s research comparing the effectiveness of clinical practices to a new entity, called the Patient-Centered Outcomes Research Institute.
AHRQ would still retain its core focus on improving safety practices and generating data on the cost and use of medical services. But Republicans argued the agency had become redundant and a waste of resources. They repeatedly proposed to eliminate its funding, each time getting blocked by Obama and other Democrats.
In 2012, as the law was being rolled out, House Republicans passed a measure to eliminate funding for AHRQ, but it was not enacted.
Earlier this year, the agency was in the spotlight again, as stories surfaced about how Price tussled with the AHRQ while serving as a Republican congressman from Georgia. An aide to Price had sent several emails pressing the agency to remove a study from its website that questioned the safety and efficacy of BiDil, a treatment for African-Americans suffering from heart failure, according to ProPublica.
The chief executive of Arbor Pharmaceuticals, the company that markets the drug, had given Price the maximum campaign contribution of $2,700. AHRQ ultimately kept the study on its site, but included a note indicating it was greater than five years old.
As the agency continues to be in the cross-hairs, there is some suggestion that bipartisan support might save it. On Wednesday, as Price spoke of eliminating duplication and finding efficiencies in the organization, Republican Representative Tom Cole struck a more cooperative tone, saying, “We look forward to working with you to find ways to stretch those dollars further.”