On March 16, President Trump released his administration's blueprint for the discretionary portion of the 2018 federal budget. This document is the administration's signal of its priorities to Congress which is responsible for passing a budget for the president to sign into law. Embedded within this budget was a proposal to dissolve the Agency for Healthcare Research and Quality (AHRQ) as a freestanding agency within the Department of Health and Human Services and to move its activities within the National Institutes of Health (NIH). No additional comment was provided in the budget as to how that re-organization would be reflected within the NIH's structure nor was there any specific budget recommendation for AHRQ beyond the $5.8 billion cut that was included in the budget for the NIH as a whole.
For almost three decades, AHRQ or its predecessor, the Agency for Health Care Policy and Research (AHCPR), has been the scientific home at the federal level for the health services and primary care research communities. Through its convening, communication, and funding functions AHRQ has been an organizing voice setting the research direction for these fields. AHRQ's authorization from Congress ties research funding to a policy and practice agenda including a focus on quality improvement, patient safety, and primary care as a foundational component of the health care system.
The linking of AHRQ's research funding with a directive to implement findings from this research has increased the relevance and impact of the agency's work. It has also made the agency a target for complaints and elimination by those who perceive that findings and recommendations supported with agency resources threaten professional autonomy and practice reimbursement.
Slow Growth And A Crowded Field
These attacks have not succeeded in eliminating AHRQ, but they have contributed to its slow financial growth over time. In 2016, AHRQ's Congressional budget appropriation was $334 million, which was a $30 million decrease from the prior year and equal to approximately 1 percent of the NIH budget for the same time period.
While AHRQ's growth has been stunted over time, other federally supported research organizations have expanded into the area of health services research. The Affordable Care Act (ACA) re-assigned AHRQ's responsibility for conducting comparative effectiveness research to the newly established Patient-Centered Outcomes Research Institute (PCORI) which in 2016 had an annual research budget of more than $500 million. The ACA also established the Center for Medicare and Medicaid Innovation (CMMI) with an average budget of $1 billion per year to do demonstrations and evaluations of delivery system innovation, a task that also had its origins at AHRQ. Even the NIH now spends approximately $1.5 billion per year on health services research-related projects.
As a field of inquiry, health services research is in the midst of a diaspora from its once unifying home at AHRQ. AHRQ at one time provided and maintained a shared narrative for collective action. This role has proven to be more difficult for AHRQ to sustain as resources and responsibility have been dispersed across multiple organizations. Individual researchers have benefited from an infusion of funds, but the parsing of these resources among multiple agencies with varying agendas has muddled the message of what the research is aiming to accomplish.
Proposed Cuts And Potential Opportunities
The coupling of a potential re-organization of AHRQ within the NIH with a proposal for a major budget cut to the NIH should raise significant warning flags for the health services and primary care research communities. It is critical that stakeholders for these communities make clear to Congress the conditions necessary to ensure that such a re-organization could be the foundation for progress — and not the basis for making up for a shortfall in other NIH funding priorities.
For example, it is critical that functions that are currently associated with AHRQ be given visibility as a defined entity, such as an institute, within the NIH. Furthermore, the move must be accompanied with designated resources that are sufficient to continue and ideally grow AHRQ's unique research functions related to improving patient safety and quality as well as its focus on primary care and implementing evidence into practice.
One potential benefit of a move to the NIH is that it is an organization, which enjoys substantial bipartisan support and as such, health services and primary care researchers might gain some shelter against the attempts to have their work undermined through political action. A second potential benefit of being housed within the NIH is that it could facilitate opportunities to connect NIH's traditional role in discovery with AHRQ's expertise in translating research into improvements in health care safety and value.
The proposal to relocate AHRQ within the NIH is a threatening change, but under the right conditions a reorganization could represent a new beginning with an opportunity to refocus within a larger new home. Organized under the NIH roof with a visible identity and appropriate funding, the reconstituted AHRQ could lead efforts on how to prioritize the allocation of resources for practice-based research and implementation science available throughout the NIH and through other federal investments.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2opYW95
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