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Strategies To Improve Funding For Health Services Research Led Both
To The Creation Of AHCPR And To Its Near-Demise Six Years Later

Health Affairs Article Focuses On Political Challenges
Facing Health Services Research

BETHESDA, MD - Despite the challenges to its original creation in 1989 and a near-death experience six years later, the Agency for Healthcare Research and Quality (AHRQ) exists and survives today because of a skillful combination of marketing, nimble political maneuvering, and private-sector constituency-building, according to a history of the agency published today as a Health Affairs Web exclusive.

Tracing the budgetary fortunes of the institution formerly called the Agency for Health Care Policy and Research (AHCPR), Bradford Gray, Michael Gusmano, and Sara Collins show that the agency's main charge, health services research, has faced an uphill fight in comparison to the biomedical research conducted by the National Institutes of Health.

The authors conclude that the successful creation of AHCPR led to activities that later made it an easy target for some health care providers who saw it as interfering in medical practice, as well as some conservative politicians who believed the agency was attempting to federalize the health care system. By shifting the agency's focus primarily to less threatening quality and patient safety missions, its leaders have been able to quell the criticism.

"AHCPR's creation fundamentally changed the politics of health services research, changing it from an obscure activity of concern to a narrow group into a visible and potentially important activity affecting politically divisive topics," the authors write. "As a consequence, the politics of health service research became much more complex and volatile, turning more heavily on its practical applications."

The authors base their account on more than 100 interviews with people involved in the agency throughout its history.

Unlike NIH's mission, researching cures to serious diseases, the authors write, the goals of health services research haven't always been easy to explain to the politicians who must decide what sort of research the government can fund. That's reflected in the federal budget for health services research, which has been about 1 percent of the amount budgeted for biomedical research.

With greater interest in curbing inappropriate medical procedures in the late 1980s, congressional support grew for a health services agency of equal bureaucratic stature with NIH, the Food and Drug Administration, and other arms of the Public Health Service. AHCPR was created under budget legislation for federal fiscal year 1990, with the support of key congressional leaders and with new funding derived both from the Medicare trust fund and from money appropriated under the Public Health Service Act.

Its early years were occupied with evaluating patient care outcomes and developing medical practice guidelines. In addition, under both Presidents George H.W. Bush and Bill Clinton, AHCPR was deployed to provide data and analysis to support health care reform efforts. Both of these activities, however, along with the departure of some of the agency's Capitol Hill champions, came back to haunt it after the political power shift of 1994.

Some Republican lawmakers began targeting the agency in 1995, claiming that AHCPR, because of the word "policy" in its name, had been the agency designated to carry out Clinton's failed health care reform plan and thus was not needed. An organization of back surgeons that opposed AHCPR's practice guidelines urged the lawmakers on. Only by reinforcing relationships with key Capitol Hill aides and congressional leaders, along with support from important private-sector allies such as physician and insurer groups, did AHCPR escape the congressional knife.

Legislation in 1999 transformed AHCPR into the Agency for Healthcare Research and Quality (AHRQ)-removing the hot-button word "policy" from its name-focused more on collecting data that the private sector can use in developing its own practice guidelines. Since then AHRQ has been the federal government's lead agency on health care quality. As such, the authors write, it has seen its budget increase substantially and has virtually wiped out all congressional opposition to its existence.

Writing of AHCPR, the authors say, "The expectation that this small research agency would have measurable real-world effects on medical practice was a double-edged sword. On the one hand, it attracted the congressional support that led to the creation of the agency, the budgetary expansion, and all the rest.

"However, it posed two dangers," they add. "First was the risk of failing to meet expectations, even if those expectations were arguably naïve. Second was the fact that activities that could result in changes in the flow of dollars had the potential to create enemies for the agency."

The article was supported by grants from the Robert Wood Johnson Foundation and the Commonwealth Fund.

Perspectives by current AHRQ Director Carolyn Clancy, former AHCPR Administrator Clif Gaus, and health services scholar Jack Wennberg accompany the article.

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research.

©2003 Project HOPE–The People-to-People Health Foundation, Inc.