Editorial: Save AHRQ; spend more on delivery system R&D

In the world of healthcare delivery system reform, Dr. Peter Pronovost of Johns Hopkins University is a rock star. His pioneering work in reengineering hospital processes that lead to unnecessary infections has been credited with preventing 50,000 deaths and saving the healthcare system over $12 billion.

Much of that work was financed by the federal Agency for Healthcare Research and Quality.

Pronovost still relies on AHRQ for funding. His Learning Lab at Johns Hopkins is in the middle of a four-year, $1 million effort to translate the interdisciplinary team approach used by the U.S. Navy on its submarines into better processes inside the nation's intensive-care units. The goal, according to the grant proposal on the AHRQ website, is “to eliminate preventable harm, optimize patient outcomes and experience, and reduce waste in healthcare.”

For decades, the nation has poured hundreds of billions of dollars into basic and applied science to devise cures for diseases. With support from the drug and device industries, which mine that research, legislation to boost the National Institutes of Health's $30 billion budget has become a bipartisan cause célèbre on Capitol Hill.

But investing in research and development for new and better ways of delivering care in the nation's hospitals and physician offices remains a stepchild in Washington. And now it is threatened with becoming an orphan.

NIH doesn't fund such research. And while the CMS, which pays for Medicare and half of Medicaid, has created incentives to improve quality, reduce harm and lower costs in the seniors' program, it does not fund delivery system R&D. Its demonstration projects—accountable care organizations, medical homes and the like—are the equivalent of trial-and-error experiments whose early stumbles could have been reduced if there had been adequate research before setting up the programs. Yet instead of beefing up funding for such research through AHRQ, Republicans on Capitol Hill are trying to kill the agency. Its paltry $465 million annual budget is a rounding error compared with the more than $600 billion the CMS spends on services.

It would be nice to think it was mere budget-balancing zealotry gone awry when a House appropriations subcommittee voted last month along party lines to kill the agency. But there has always been an ideological agenda behind efforts to kill AHRQ. That's tied to the fact that it also evaluates the merits of competing medical technologies, either through technology assessments for the CMS before it makes national coverage decisions, or through comparative effectiveness research for dissemination to the public.

That's what Republicans have in their crosshairs. They don't just want to kill AHRQ. They would like to defund the Patient-Centered Outcomes Research Institute (PCORI), which was expressly set up to fund comparative effectiveness research. They also want to abolish the CMS Innovation Center, which funds the demonstration projects.

They apparently don't want people to know what works best for which patients in healthcare.

There has always been a layer of special-interest politics behind the anger aimed at technology assessment agencies such as AHRQ and PCORI. In the 1990s, the precursor agency to AHRQ was nearly voted out of existence after it published a report showing that rest and painkillers worked just as well as back surgery in managing chronic lower-back pain. The nation's spine surgeons found a receptive ear in the Newt Gingrich-led Congress, which sharply curtailed the agency's authority and budget.

Recently, the drug and device industries have worked behind the scenes to limit the influence of PCORI's comparative effectiveness research. They have succeeded in limiting the CMS' ability to make use of its findings, for instance.

During last month's markup hearing, subcommittee chairman Rep. Tom Cole (R-Okla.) seemed taken aback when AHRQ backers, led by Rep. Lucille Roybal-Allard (D-Calif.), pointed out the tremendous improvements in patients' lives achieved through AHRQ-funded research. He suggested HHS could move some of AHRQ's functions to other agencies, ignoring the fact that they are already underfunded because of budget sequestration.

The healthcare system needs a huge bump in care delivery R&D, just as much if not more than NIH needs its funding increase. It also needs more comparative effectiveness research, so ongoing efforts to eliminate waste rest on sound science.

Turning the stepchild into an orphan will be no solution at all. This latest attempt to kill AHRQ deserves to fail.