Averting the Ax at AHRQ

Congress is infected with the budget-cutting bug, and building an effective immune system requires political savvy. Sometimes, it’s simple (“We bomb terrorists” or “We process Social Security checks”), but sometimes an agency struggles. Case in point: AHRQ.

A House subcommittee recently voted to eliminate the Agency for Healthcare Research and Quality (AHRQ) as of Oct. 1, 2015, the start of fiscal 2016. If you hadn’t heard the news or aren’t sure why you should care, that’s exactly the point.

The GOP-led House Subcommittee on Health, Employment, Labor and Pensions (HELP) first voted to ax AHRQ back in 2012, along with other big government cuts; the agency escaped thanks to political gridlock that led to continuing budget resolutions instead of individual appropriations bills. Now, with the GOP in control of both houses of Congress, AHRQ has again been “terminated,” to quote the legislative language. But before railing against the Republicans, look at it from their viewpoint.

What HELP did was take about a half-billion dollars from Obamacare bureaucrats and use it as part of the budget boost given to scientists seeking to cure cancer, Alzheimer’s disease and similar ills at the National Institutes of Health, and to those at the Centers for Disease Control and Prevention working to protect Americans from dangerous epidemics such as Ebola.

You got a problem with that?

Of course, there’s another side to the story, assembled by Friends of AHRQ. In a nation that spends some $3 trillion on health care, a Friends of AHRQ brochure notes, the agency works to answer “hard questions about the availability, quality and costs” of that care, according to Joseph Antos of the conservative American Enterprise Institute. Moreover, finding what works and what’s wasteful can “help close the fiscal gap” in the federal budget, avers Dr. Brent James, a senior leader of Intermountain Health Care in reddest-of-red-states Utah.

“NIH is great. CDC is great,” says Dr. David Penson of Vanderbilt University Medical Center in Nashville, yet “no one but AHRQ” takes on the job of delivery system research. The four key areas of that research include making care more accessible, safer, more effective and more efficient.

Excited yet?

One problem is that while clinical research and fighting epidemics are popular causes that will also pump money into various Congressional districts, eliminating health care “waste” brings no local political benefit. If anything, the effect is the opposite. Clamping down on waste can look an awful lot like bureaucratic interference to those whose income is jeopardized.

AHRQ’s predecessor learned that the hard way when it was targeted for elimination by a House with a new GOP majority in 1995 after spine surgeons vigorously complained about guidelines targeting “overuse” of back surgery. What was then called the Agency for Health Care Policy and Research survived by changing its name and narrowing its mission.

In some ways, today’s situation is worse. AHRQ is endangered not by influential enemies but because no influential Republican sees any accomplishments to justify averting the ax.

To avoid extinction, AHRQ needs to take three immediate actions:

1) Get a new leader. As I wrote in 2013, when researcher Richard Kronick, PhD was named AHRQ’s director, the appointment seemed driven by defensive politics. The announcement wasn’t even posted on the AHRQ website but was announced in the Department of Health and Human Services’ daily electronic newsletter.

Kronick had worked in HHS on implementation of the Affordable Care Act and, before that, on Medicaid in Massachusetts. That background did not bode well for bonding with the GOP majority in the House, and today Republicans control the Senate, too. Republican opposition to “Obamacare” has often been frenzied, fanatical and unfair, but the job of an agency head, particularly at an embattled one, is to get along with those who control your budget. Since, for the moment, the voters aren’t going to fire the Republican Congress, it’s Kronick who’s got to go.

Who should replace him at AHRQ? Intermountain’s James reportedly turned down the AHRQ position in the George W. Bush administration, but he might take it as a short-termer today for the good of the field and the nation. James trained as a surgeon and statistician and founded Intermountain’s Institute for Healthcare Leadership. He’s thoughtful, smart and, though a Republican, a genuinely apolitical scientist who’s both widely respected and well-liked.

The word “scientist” is the key. Though AHRQ calls itself a “science agency,” that’s not the general perception. If James won’t take the job, my next choice would be another prominent clinical scientist in the health services field, Dr. Peter Pronovost of Johns Hopkins’s Armstrong Institute for Patient Safety and Quality. Unlike James, Pronovost wouldn’t have to move, only lengthen his commute from Baltimore. A charismatic clinician who was a recipient of a MacArthur Foundation “genius grant,” Pronovost would bring brand-name scientific credibility to an agency mired in anonymity.

How anonymous? At a time when health care reform has been constant front-page news, AHRQ has not been mentioned in the New York Times during the past year – including when the House committee voted to eliminate it. During that time, The Washington Post made a passing reference to AHRQ statistics in a story on infections, but the Post, too, made no mention of the agency’s possible termination. The planned agency execution rated only a line or two even in publications like The Hill and Politico.

2) Change the agency’s name and, if possible, affiliation. Yes, this was done once before, after the 1994 GOP threat met, from the Agency for Health Care Policy and Research to AHRQ. But I would suggest that in the short attention span of today’s world, explaining what is meant by “health services research” or why “quality” is not what I automatically get from my local doctor and hospital are losing propositions.

In any event, “health” and “health care” are wonk words that stir no positive emotions. In contrast, the public, press and politicians perk up when they hear about “medicine.” For better or worse, names and labels define us: think “Archibald Alexander Leach” vs. “Cary Grant” or, for that matter “consumer-driven health plans” vs. “defined contribution health insurance.”

Without changing its mission, and in keeping with the “science” and “medicine” themes, it’s time for AHRQ to become the Agency for Translational Medicine. Or, perhaps better, the National Institute for Translational Medicine.

If you can’t beat ‘em, join ‘em.

3) Personalize the benefits. In his 2015 presentation to Friends of AHRQ, Kronick spoke about the agency’s “multiple chronic disease” program. Curious, I looked at the web page of the Congressional Diabetes Caucus, formed back in 1996, and now comprising the largest caucus in Congress. The Congressional Diabetes Caucus has close to 350 members. In listing its accomplishments in regards to diabetes care, the group mentions NIH, the CDC, the Medicare program, the Indian Health Service and the U.S. Postal Service, for a diabetes stamp. AHRQ is MIA.

AHRQ, the organizations that make up Friends of AHRQ and those in the research community who receive AHRQ grants have spectacularly failed to crystallize for members of Congress or the public the real benefits of what AHRQ and health services research accomplish.

AHRQ helps keep the sick and vulnerable safe in hospitals, and grim statistics show that wealth, education and political clout provide no extra protection from medical error. AHRQ helps make sure the discoveries at NIH go from the bench to the bedside, whether your problem is diabetes cancer or one of those infections the CDC is trying to prevent. Even more important, an AHRQ program a day keeps the doctor away, whether it’s because of preventive care that improves health or preventing inappropriate and unneeded operations.

Call this the heart attack you don’t have, and the heart bypass you never get when taking a pill or two works just as well. Are you listening, middle-aged members of Congress?

That’s the science story AHRQ needs to tell and sell. Meanwhile, to cure the immediate political infection, AHRQ need a dose of new leadership, a new name and new outreach efforts to those who control its fate.

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5 replies »

  1. Interesting article with some insightful perspectives, Michael. In full disclosure as someone who’s worked with – and funded by – AHRQ and other government agencies, I am admittedly a supporter of AHRQ. Reason-being, it is an agency that understands the importance of public funding, but also devotes resources and funding to dissemination of findings. Could it be better? Sure. I can say that about many areas of the government.

    In health IT anyway, AHRQ was one of the earliest funders – before ONC was established. Overall, the research and policy world needs to be tied more closely to the non-academic real world. Both AHRQ and NIH are structured in a way that benefits strong grant writers. We need better ways to get the findings into industry, so I agree with your focus on translation. For example, I’m aware of plenty of AHRQ-funded health IT findings… I probably couldn’t name a single health IT finding that came out of NIH-funded research. It’s usually buried in peer-reviewed literature somewhere, likely categorized as disease-based, as NIH uses an organ-based structure vs. AHRQ which focuses on the delivery system. We’re still far from the day that health IT vendors and health/hospital systems are putting research into practice. I think the elimination of AHRQ now would further hinder where we could be.

  2. Three issues from the Republican view that haven’t been addressed yet:
    1.) that $408m per year comes from NIH. They’d rather it stay with NIH to do basic/clinical research.
    2.) Per NIH RePORTer, NIH already does 4x the amount of health services research per year that AHRQ does. Either NIH should stop, or AHRQ should go. Why is this research being done at two places?
    3.) PCORI is now fully online, and has yet another duplicative mission with AHRQ and NIH’s health services research programs (three homes for effectiveness research?!). As a home for PCOR, it’s attractive from an appropriator’s point of view, since it has a dedicated non-appropriated stream of funding due to the ACA (it taps health plans $1-$3 per plan, which goes right to PCORI), freeing up money in the annual appropriations bill if all effectiveness research will be done through this home. Further, given that another agency is now charged with conducting research on the effectiveness of clinical and health services, why not eliminate one (AHRQ) and free up funding within the appropriations bill for priorities like NIH?

    If the community wants AHRQ back – despite the fact that NIH and PCORI are also doing health services research – then it will have to be bought back using NIH funds. Is that what we really want?

    Also, the science community hasn’t done a good job of why there need to be three homes for effectiveness research (AHRQ, NIH and PCORI). Republicans clearly want one home (PCORI). For them, it’s not about the science that AHRQ is doing, it’s about the management of the federal R&D portfolio, and working within the BCA caps to find new funding to scale up priority programs like NIH. Given that there doesn’t seem to be a good rationale for keeping AHRQ from a management perspective, and the funds will be used to plus up accounts like the NIH, I’d say give the Rs their management victory and take the money for NIH et al.

  3. Good question about the cost-effectiveness money, Matthew. The problem is, I agree, that effective government actions are ignored while free-market ones, even when overly expensive (subsidized Medicare Advantage plans, anyone?) get ignored. Without ARRA, with all its problems, we’d be stuck with many more paper records and their demonstrated problems.

    Bobby, you may be right about the difficulty of the AHRQ job even for Brent. But if they accompanied his appointment with something more than bureaucratic shuffling of the deck chairs, as I’ve suggested, he would get a real hearing on Capitol Hill.

  4. Interesting post. I’d heard this news.

    Dr. James is one of my mentors from the early 90’s (we all took the extensive IHC Healthcare CQI course under his auspices when I was with the Nevada-Utah QIO for my first of three tenures). He is indeed an astute, inspiring guy.

    I would advise him to again turn them down. It’d be another Karen DeSalvo move. Unless they could rename the agency, like you’ve proposed (nice idea), and give him time (and funding) to actually get something accomplished. But we have policy ADHD in DC in general, and with an election year coming on and a new federal shutdown looming, I’m dubious.

    AHRQ is indeed vulnerable. Doing stuff like letting an $800k RFP for a 2-yr “workflow study” contract to study the upshot of their PRIOR 2-yr “workflow study” (which was 10 years behind the times even as the toner dried) doesn’t help, as I noted back in 2012.


  5. Michael. Excellent piece with practical suggestions. I fear though that it might be too late. AHRQ Like most government agencies can’t market it’s way out of a paper bag, and Republicans may hate waste in government spending but they love free market growth in health care. Even if 60%+ of that growth comes from government spending. Add to that the “invisible” saved life vs kid with cancer problem, and AHRQ’s role seems bleak.

    One question. What happened to all that cost-effectiveness money for AHRQ in the 2009 ARRA legislation? If it got spent, hadn’t AHRQ better tell us about it quick?