For those of us that live and breathe health services research, the past two weeks of House and Senate appropriations committee markups give us a sense of déjà vu, frustration, and cause for reflection. The Agency for Healthcare Research and Quality (AHRQ) was once again placed on the chopping block in the fiscal year (FY) 2016 spending bill for the House of Representatives Labor, Health and Human Services, Education and Related Agencies Subcommittee, and the agency’s budget was slashed by 35 percent in the Senate Subcommittee’s bill.

We’ve heard this song before. In 1994, AHRQ (then the Agency for Health Care Policy and Research) suffered a near-death experience in retaliation to unpopular evidence. More recently, the agency was also proposed for ‘termination’ in the House’s FY 2013 spending bill that, though released, was never considered by the subcommittee. We understand that subsequent House spending bills that weren’t made public in FY 2014 and 2015 also included the same language we see today.

We know AHRQ’s work is important–critical, in fact, when we consider the challenges facing health care. We witness preventable medical errors and unnecessary care that waste valuable resources (dollars and labor); observe the sciences being pitted against other sciences; see medical discoveries and effective advances that languish on paper or in laboratories never to reach patients or improve their health, withering away while others rediscover their findings; and continue to debate the best way to pay for care so that quality and value are enhanced.

The challenges are infinite. So why, at a time when we need to understand our health system most, is Congress proposing the abolishment of an agency that, at its core, is tasked with helping us address many of these challenges? Challenges that by policymakers’ own admission, are top of mind?

Why, 20 years later, are we still struggling to defend the flagship agency for the field of health services research–the research that tells us what works, for whom, under what circumstances, and at what cost? [click to continue…]

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I have to begin any discussion about how much doctors make with a full disclosure – I’m a physician. I, like all of you, enjoy making more money than less money, so take all of what I say in that context. However, it is possible to have data-driven conversations about how much people who work in health make versus other sectors, and what that might mean for health care spending.

In a recent piece in Health Affairs, Sherry Glied, Stephanie Ma, and Ivanna Pearlstein did just that. In “Understanding Pay Differentials Among Health Professionals, Nonprofessionals, And Their Counterparts In Other Sectors” the authors state:

About half of the $2.1 trillion of US health services spending constitutes compensation to employees. We examined how the wages paid to health-sector employees compared to those paid to workers with similar qualifications in other sectors.

Every time I write about health care spending, I like to remind people that one person’s waste is another person’s income. Money that isn’t spent on health care isn’t put into a big pile and burned. It’s put into other people’s pocket. Even the first line of the abstract here is instructive. More than one trillion dollars a year is spent on employee compensation for health care. That’s more an 8% of GDP alone. We spend a lot of money employing people in the health care sector.

The researchers used data from the March Current Population Surveys from 1979 through 2013, and controlled for many other factors that could be associated with income. If you’re interested in the full methods, I encourage you to go read the paper, as it’s well written. I want to focus on the results here.

Workers in health care are more educated in general than those in other sectors. Non-professional health care workers average between 0.3 and 0.6 years more in schooling that non-health-sector employees. Professional health care employees, like nurses and physicians average from more than 1 to almost 6 more years of schooling.

After controlling for other factors, workers in health care make about 3% more than those of comparable workers in non-health care sectors. That’s more, but not as much as many might think. The spread is not even though. Those in the bottom quartile of health care employees make about the same as non-health care employees, while those in the top quartile make about 4.7% more than their non-health care counterparts.

Health care professionals, on the other hand, make quite a bit more. Nurses make about 40% more than would be predicted by education, experience, and demographics. Physicians earn almost 50% more than would be predicted. The spreads are different, though. Nurses at the lower end of the pay spectrum earn more than their counterparts in the non-health care world, compared to those at the higher end of  the pay scale. For doctors, the opposite it true; there’s more of a difference at the higher end of the spectrum.

Contrary to what many might think, having a job in the health care sector does not lead to larger salaries, on average, compared to working in other areas. Nonprofessionals in health care earn very similar amounts to those outside of health care. Those employed in nursing homes earn less than you would expect, even. The exception is professionals, including nurses and physicians. But such professionals comprise a minority of the health care workforce, making it unlikely that high salaries, in general, can be blamed for outsized health care spending. Physicians compensation is less than 10% of all health care spending, and nurses account for less than 7%. As this paper reports, if tomorrow somehow policy makers were able to strip all extra pay for health care professionals above what you’d expect they’d make in other sectors, overall health care spending would be reduced by only 6%. Further, given that the pay differentials haven’t been increasing over recent time, doing so would do nothing to bend the curve in the future.

The conclusion of the paper is as follows:

These results suggest that efforts to reduce the rate of growth in prices paid for health care services cannot be accommodated primarily through reductions in the pay of health-sector employees. Instead, such efforts will likely require providers to improve their productivity, producing the same services with fewer, or less costly, labor inputs.

I think that makes a lot of sense. I look forward to hearing what you think, in comments or on Twitter.

Aaron

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The following is a statement from Dr. Lisa Simpson, president and CEO of AcademyHealth: 

Yesterday, the Senate Appropriations Committee passed its Labor, Health and Human Services, Education, and Related Agencies appropriations legislation. Starting with a spending level of $3.6 billion below current levels, there were bound to be painful cuts. Indeed, the Agency for Healthcare Research and Quality (AHRQ) is cut by 35 percent–a deep cut as the result of the woefully inadequate levels of available discretionary spending.

The bill isn’t without its winners, at least some of which come at AHRQ’s expense. The National Institutes of Health (NIH), for example, receives a much needed $2 billion increase. As the Subcommittee Chairman Roy Blunt highlighted in a recent op-ed in The Hill, “Now is the time to prioritize biomedical research to increase critical life-saving medical treatments and high-quality cures available to all Americans.”

Like health services research, biomedical research is a critical function of the federal government. There’s no denying that investments in NIH help discover cures for patients and strengthen the economy. The Chairman notes, “NIH-funded biomedical research is the catalyst behind many of the advances that are now helping Americans live longer and healthier lives.” But, if biomedical research is the “catalyst,” AHRQ’s health services research is the fuel to keep the fire burning. Without evidence about how to optimally deliver cures to patients, or how to make the best use of the cures already available on the market, NIH’s medical discoveries will fall short of their promise to patients. These two agencies have important, complementary, and mutually beneficial functions.

AHRQ’s unique role in collecting data and funding health services research on the performance of the health care system helps doctors and health systems develop and test innovations on how to deliver high quality care in less costly and more effective ways. Our nation spends $3 trillion annually on health care–the largest share of which are federal purchases through Medicare, Medicaid, the Federal Employees Health Benefits Plan, insurance exchanges, TRICARE, and veterans’ health care. Health services research tells us as much as 30 percent of this spending is wasted on inappropriate, unnecessary, and sometimes even harmful care. Already, our nation spends less than one-tenth of one cent on health services research to determine how to do better: to deliver the best possible care, at the greatest value, with the best outcomes. Under the Senate’s spending bill, we’d spend even less. With health care spending continuing to rise, can our nation really afford the short-term gains as a result of AHRQ cuts?

Chairman Blunt asserts, “This is a time of promise in medical research and the United States should be at the forefront of this era. To do so, we must commit to paying for the research to do it.” AcademyHealth and the community we represent couldn’t agree more. But our nation needs to invest in the full continuum of health research–basic, clinical, prevention, health services, and translational research–to get the best return on NIH investments. AHRQ is a critical pillar of America’s health research enterprise, and worthy of fully restored funding in fiscal year 2016.

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In its landmark 50th anniversary, the Social Security Act legislation that contains Medicare and Medicaid has undoubtedly been a force to be reckoned with throughout the course of health care’s history. This legislation–the 97th bill introduced in Congress that year, passed in six months, and signed by President Johnson–has been an issue of debate and a source of much contention over its fifty years, but panelists sitting on both the Medicare and Medicaid 50th Anniversary special sessions noted how the programs’ longevity is astounding.

50th Anniversary of Medicaid

During this panel, some of Medicaid’s leading policy thinkers and researchers discussed the program’s evolution since the law’s passage in 1965: its history, what we know from research, where there are opportunities and challenges moving forward, and the political dynamics involved. Sara Rosenbaum kicked off the session with a reminder:

“While Medicaid has been a vital source of health insurance, growing more so every year, and has been the basis of tremendous health services research into the health care needs of poor and disadvantaged populations and how well financing meets those needs, Medicaid is also a law. And Medicaid as a law has had a remarkable life in the law, which is something that is overlooked in the program’s history.”

Much of the story of Medicaid policy over the past half century is the story of the courts—an aspect “absolutely central to understanding it.” Through the courts and congressional action, Medicaid has experienced many evolutions, and yet, despite those changes, its basic structure and foundation remains intact; it’s a partnership between the federal government and the states that has endured for 50 years and is a fascinating case study for those interested in health policy history.

Reaching an apex in NFIB v. Sebelius, Medicaid has been the battleground on which the fraught question of federalism has played itself out. Over time, the program has evolved to meet changing population needs. Among its adaptations have been meeting children’s needs beyond health insurance through the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program; adding the disabled, elderly, and blind populations to the program; and severing ties between it and welfare.

From a state lens, Medicaid’s history and its opportunities and concerns have transcended politics. As Trish Riley, National Academy for State Health Policy, said, “It would be a mistake to base too many conclusions based on the party in control” because the cost and growth of the program is a concern for all, and that concern increases all the time. Interestingly, she noted, while states are concerned about cost, 60 percent of those incurred costs have been optional; states chose it.

Yet, as all panelists noted in some capacity, Medicaid is wrought with difficulties. With the growth in the program and the variation in populations served, there is enormous complexity. Furthermore, as Benjamin Sommers, Harvard School of Public Health, described, managing and improving upon Medicaid becomes increasingly challenging. Some people don’t realize they have Medicaid, what it entails, or when their coverage has lapsed–factors that will only become more complicated under the Affordable Care Act. There is also the added complexity of multiple types of care delivery, in other words, ’50 states, 50 Medicaid programs.’ As a result, Medicaid is difficult for researchers to study.

The areas where researchers have studied, Genevieve Kennedy said, reveal that no matter where Medicaid is expanded, no matter the implementing state and its enthusiasm or lack thereof, public health insurance responded and there was lower uninsurance among the target population. Beyond coverage, researchers are consistently finding an increased likelihood of having a usual source of care and receiving a broad range of preventive and other health services. There is also evidence that Medicaid improves self-reported mental and physical health and depression screening.

Moving forward, there is much space for health services researchers, who can help answer questions about things such as program trade-off, i.e., “Medicaid compared to what?” In a world contemplating different ways to provide coverage, it is difficult to know what to make of the literature on quality and the other alternatives available. Medicaid continues to grow despite being under attack, and those accounting for the difference between rhetoric and reality, are health services researchers.

50th Anniversary of Medicare

“The objective of this session is not to celebrate the triumphs of the past,” said Robert Reischauer setting the stage for the panel, “…but rather the purpose of this session is to reflect on and discuss the roles that HSR has had on the evolution of Medicare.”

Don Berwick did this by citing evidence on variation in practice as the most important aspect of health services research to inform Medicare policy. Using data from geographic variations to craft legislation that works for diverse states continues to be vitally important. He also outlined a “wish list” of topics for health services researchers to focus on over the next three decades:

  • Research on how to train physicians to change the delivery system;
  • Transition models and financial plans;
  • Data on scale and change in delivery systems;
  • How to change the demand of consumers;
  • The study of waste and its forms;
  • New roles, workforce distribution; and
  • Telemedicine and telehealth.

Karen Davis spoke to the history of the program: how health services research shaped Medicare and how Medicare has impacted health services research. “Medicare has shaped the health services research community by developing the databases for claims data…it provided a wealth of information that let us understand what was going on with the health system as a whole,” she said. She also cited the desegregation of hospitals as a way in which Medicare impacted health services research. Due to Medicare’s provision to receive hospital funding, hospitals had to be in compliance with the Civil Rights Act. Health services research documented the increased use of hospital services of elderly African Americans. She concluded that research has helped shape and make Medicare an innovator in coverage design and payment/delivery system.

Jon Christianson discussed the impact of health services research on private markets and competition on Medicare and focused on managed care programs. The opportunity for future research in these sectors, he outlined, include payment options and how risk is handled and noted the importance of private sector research on influencing Medicare. He ended by speaking to the current challenge of consolidation on the provider side and called for health services researchers to help address it.

David Durenberger concluded by addressing the ongoing need for health services research to inform policy and help lawmakers make decisions on health care reform legislation. Highlighting Medicare’s impact on HSR, he cited Medicare as a rich source of comparative data for health services researchers. He stressed the importance for health services researchers to stay the course and continue to keep lawmakers focused on the goal of health care reform by using evidence and data.

Each of these panels at the 2015 Annual Research Meeting succeeded in providing a panoramic view of the two programs, considering the past and future of Medicaid and Medicare and thinking long-term about their futures in an era of health reform.

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2015 ARM Wrap-Up

by Academyhealth on June 17, 2015

The Annual Research Meeting continued on Monday, June 15. We are excited by the new and innovative research that was presented and discussions that occurred at the meeting. We are energized about the groundbreaking work that those in our field are producing and its potential to positively shape the U.S. health care system.

What Do Medicaid Policymakers Say They Need from Researchers?

This session, moderated by AcademyHealth senior director, Michael Gluck, explored the second in a series of Listening Project reports released by AcademyHealth in February 2015. The session began with an overview of the report entitled, “The AcademyHealth Listening Project: Improving the Evidence Base for Medicaid Policymaking”, by AcademyHealth senior manager, Lauren Randomski. Fellow panelists included, Catherine Hoffman, California Medicaid Research Institute, Lucinda Jesson, Minnesota Department of Human Services and Anne Schwartz, Medicaid and CHIP Payment and Access Commission.

Randomski explained  the premise of the report, which is that if research is to be useful the first step is to look at the right questions. To answer these questions, the research team interviewed federal and state policymakers, analysts and national associates. According to Randomski, results of the report show that better understanding of access to care, quality of care, and health outcomes are needed.

Following the overview, panelists presented related findings and information. Schwartz shared thoughts on Medicaid and Medicare research overall, while Jesson discussed ongoing efforts in Minnesota and Hoffman detailed three key messages related to research: 1. Tricky Business, 2. We Need Results….um…yesterday and 3. What it Takes to Free the Data.

The panel closed with a discussion around the fact that Medicaid research is challenging, but worthwhile and rewarding.

To read the full report, visit the AcademyHealth website.

From Vision to Action: Measures to Mobilize a Culture of Health

This session, moderated by Alonzo Plough, focused on the Robert Wood Johnson Foundation’s (RWJF) framework for a culture of health, or a society in which everyone has the opportunity to live the healthiest life possible. Panelists discussed three research programs solicited by RWJF to examine the factors necessary to implement the framework, including “evidence for action, policies for action, and systems for action.

Nancy Adler from the University of California San Francisco began the panel by calling for health care systems to take on additional roles and responsibilities to improve health care disparities. Glen Mays of University of Kentucky, College of Public Health, then further explained the idea behind “systems of action,” which seeks to widen lens of HSR-focus more at the intersection of sectors and stressed the importance of linking people to needed health and social support services as a core function of public health. Lastly, Scott Burris of Temple University-Law School posed the question of how to best use research to “drive into police” and how to engage and “make sense of research across disciplines.

Advancing the Field of Dissemination and Implementation Research

Dissemination and Implementation Research, or D&I, may vary based on research discipline or by the institution funding the research. Regardless, it’s essential to improving health, said David Chambers, National Cancer Institute. D&I research is not a new phenomenon; it’s been around for decades—in work around effectiveness and efficiency, practice variance and safety, and evidence-based medicine—and centers on asking how we can apply what we know to try to improve health and health care of populations.

Unfortunately, there is a long uptake between policy and practice. Chambers mentioned that it takes 17 years to turn 14 percent of original research to the benefit of patient care. “If we ignore all we learn about how we get the information out there and if we focus on publication as the Holy Grail,” he said, there are “many important findings we lose and that don’t see the light of day.” Yet, there is a silver lining: there are increasing opportunities from AHRQ, CDC, NIH, PCORI, WT Grant Foundation, and many more. Areas that are ripe for exploration include sustainability of evidence-based practices in changing context and their adaptability over time; implementation of a set of interventions; impact of dissemination strategies on practice; and scaling up practices across health plans, systems, and networks.

Panelists noted that even the thinking around D&I research has progressed; researchers are now trying to think more sensitively about context—to population and community health systems—than they had previously. Felica Jones and Kenneth Wells demonstrated this by describing their work with minority communities, where their work centers on efforts to build trust and conduct community-based participatory research. As they noted, it’s not just about the research; it’s about documenting and improving health care capacity, and there’s a social justice aspect to the work.

As closing advice for attendees,the panel suggested they pay better attention to the implementation that is taking place all the time in a number of different settings because that is where researchers can find myriad opportunities.

Presenting Research in Compelling Ways: A Student Competition (Translation and Communications Interest Group)

Monday wrapped up with the second annual student competition, sponsored by the AcademyHealth Translation and Communications Interest Group. In this year’s competition, four students presented on the 2014 Article of the Year, Plan–Provider Integration, Premiums, and Quality in the Medicare Advantage Market. Health Services Research, by Austin Frakt.

[click to continue…]

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The following is a statement from Lisa Simpson, M.B., B.Ch., president and CEO of AcademyHealth: 

“The House Appropriations Committee fiscal year 2016 spending bill for the Departments of Labor, Health and Human Services, Education and related agencies is a devastating attack on health research funding at a time when this work is most critically needed by patients, health care providers, and policymakers alike.

“Our nation spends more than $3 trillion annually on health care, with the federal government purchasing the largest share through Medicare, Medicaid, Federal Employees Health Benefits Plan, insurance marketplaces, TRICARE, and veterans’ health care. Research by AcademyHealth’s members tells us too many patients receive sub-optimal, unsafe, and even harmful care.

“We can do better, and health services research tells us how. Research, datasets, and tools supported by the Agency for Healthcare Research and Quality (AHRQ) are used by every actor in health care. Patients and their caregivers; physicians, nurses, and other health care providers; health systems and hospitals; public health professionals; federal, state, and local policymakers; and purchasers and payers, such as employers and public and private insurers, all use AHRQ’s work to make health care safer; of higher quality; and more accessible, equitable, and affordable.

“Yet, the Labor-HHS spending bill ‘terminates’ AHRQ–the only federal agency with the sole purpose of generating the evidence necessary to build a higher-quality, higher-value health care system for the American people. And, in addition to this egregious assault on health services research, the bill slashes mandatory funding for patient-centered outcomes research by $100 million, bans the use of discretionary funds on this research, and also cuts $6.2 billion from the Center for Medicare and Medicaid Innovation (CMMI).

“If policymakers truly want a less complex and costly health care system that improves patient outcomes, it is not enough to fund research that discovers and develops new cures. Patients, providers, and policymakers need health services research and patient-centered outcomes research to understand how to best deliver those cures in the real world so patients can benefit today.

“Put plainly, AHRQ, along with these other critical research programs, help Americans get their money’s worth when it comes to health care. We need more of its evidence, not less. Investments in discovery and development will fall short if we don’t have research on how best to deliver them to the right patients, at the right time, and in the right setting.

“As the leading national organization representing the field of health services research, AcademyHealth believes AHRQ plays a unique and necessary role in identifying and supporting practical, actionable information to improve health and health care, and we urge lawmakers to preserve the agency and its funding.

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DS2_6476

The 2015 AcademyHealth Annual Research Meeting got off to a strong start Sunday, as some of the brightest minds in health services research flocked to the Minneapolis Convention Center to discuss the latest, most cutting-edge work in the field. With sessions covering everything from the milestone anniversary of Medicaid to the Supreme Court’s impending decision on King v. Burwell to the ‘$2 trillion question’ of whether the slowdown in health care cost growth will continue as well as 18 tracks that covered themes including behavioral health, complex chronic conditions, health information technology, and maternal and child health, there was something for everyone.

With the takeaways from the day’s sessions–recapped below by AcademyHealth staff–we’re optimistic that the 2015 meeting will continue with the same energized, upward momentum:

Making Sense of Evaluation Data for Policy: Meta-Analysis and a Data Visualization Dashboard

During this first session of the Innovation Station, speakers Anupa Bir, Robert Chew, and Kevin Smith of RTI International and Timothy Day of the Centers for Medicare and Medicaid Innovation demonstrated a data visualization tool—an interactive dashboard—designed to analyze the 108 projects within the Health Care Innovation Awards. Through their presentation, panelists revealed how the dashboard allows researchers to manipulate variables and characteristics of interest (e.g., projects on health information technology), and help both program managers and policymakers alike understand project relationships and patterns without doing programming and analysis. Ultimately, tools such as this one could help facilitate the translation of research into policy and practice.

Evidence-Driven Innovation in Minnesota

This morning’s session, Evidence-Driven Innovation in Minnesota, moderated by AcademyHealth’s Enrique Martinez-Vidal, brought together local experts to discuss the evidence-based innovations in the state.

Katie Burns of MNsure began by highlighting how the 2008 Minnesota health reform law helped the state more effectively create the Minnesota state exchange. She noted the successes and challenges the state faces, such as consumer outreach and support. Brokers and navigators, for example, are important partners with the state in reaching the uninsured eligible to purchase private coverage or utilize coverage, and plan comparison tools are vital in consumer support. However, given the high rate of insured in the state, the remaining uninsured population will be more expensive and harder to reach.

Echoing Katie Burns, Healther Petermann of the Minnesota Department of Human Services, pointed to the unique innovations and evidence in the state, which have also led to both challenges and opportunities in implementation. Petermann discussed Minnesota accountable care organizations (ACOs), particularly Integrated Health Partnerships and the important role of flexibility, which allows for local responsiveness and innovations, as a key factor in their success.

Offering a public health perspective, Daniel Pollock of the Minnesota Department of Health, emphasized the importance and success of locally-driven interventions and programs, such as Minnesota’s Statewide Health Improvement Program (SHIP), which takes place in schools, businesses, and communities. Notable SHIP successes include those in Duluth for tobacco control, Fergus Falls for fresh foods, Madelia for non-sugary drinks, Mankato for small business initiatives, Olmsted County for affordable housing units and a smoke-free housing community, and tribal areas for a farmers market to provide healthy eating options and economic growth. When programs are locally-driven, the community decides, determines, and is invested in their success.

Lastly, Jennifer Lundblad of Stratis Health presented Stratis’ contributions to the growing body of health care reform evidence: improving care transitions and reducing unnecessary readmissions, which built on an existing body of evidence and contributed new perspectives; using health information technology to improve quality and safety as well as empirical data to ultimately improve policy and programs; and building rural palliative care capacity, which resulted in a new model and a base of evidence where there was none before.

Minnesota’s long history of health care reforms and efforts in the state continue to provide insight on how those ‘on the ground’ can continue to improve and advance ACA implementation.

Late Breaking Session: 2015 Coverage and Marketplace

This year’s Late-Breaking Abstract Series kicked off with a discussion on the current standing of coverage and the marketplace. Moderator Sharon Long, of the Urban Institute, kicked off the panel and noted the consistencies in research and findings across the board about gains in insurance coverage in the post-ACA era. The research, still in its primary phases, all highlighted the significant early gains under the Affordable Care Act, particularly in coverage, while also highlighting the continuing challenges of reaching the remaining uninsured.

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My colleagues and I like to tell ourselves, if not others, that our research makes an impact by informing policymakers. That’s something that should be measured. For comparative effectiveness research (CER) specifically, Joel Weissman and colleagues recently did so.

In a study published in the Journal of Comparative Effectiveness Research, Weissman et al. surveyed Medicaid program medical and pharmacy directors in all states. Their overarching question: How do senior coverage policymakers view and use CER? (The sense of policymaking here is about what medical treatments to cover through a Medicaid program, and in what ways.)

One thing they learned is that Medicaid policymakers love RCTs, consensus statements or guidelines from national professional societies, and systematic reviews. About 90% of them said they used evidence in these forms. About 75% said they used expert opinion, and about 60% used observational studies with external (not the plan’s) own data. Less than half (45%) used observational studies based on the plan’s data.

It’s a bit difficult to interpret these statistics, however, since consensus statements, guidelines, and expert opinion are themselves often based on studies, whether experimental or observational. What these results may be telling us is how influential the final packaging may be. The best way to get an observational study to be used by a Medicaid program, for example, may be to try to get it worked into a consensus statement, guideline, or systematic review.

That advice looks even better if we consider how useful these policymakers found each type of evidence (or evidence delivery method). The authors found that observational studies are a lot less likely to be perceived as “very useful” than other some other evidence sources.

The percentage who said each type of evidence or information was ‘very useful’ in setting policy was highest for RCTs (73%), followed by 68% for guidelines, 53% for systematic reviews, 42% for expert opinion, 20–21% for observational studies and 8% for patient experience/advocacy.

(There was a lot less variation when weakening the criterion to “at least ‘somewhat useful’”.)

The authors also asked about confidence in different research sponsors and sources. The results are in the chart below. Keep in mind that a study could fall into more than one category (e.g., a peer-reviewed publication that is sponsored by NIH). It looks like PCORI and the USPSTF have some work to do in boosting confidence to Medicaid policymakers.

weissman fig 2

Respondents reported various barriers to using CER. The top ones point to the need for more research and more cost/budget analysis.

weissman fig 3

That about 45% reporting “the lack of an independent body that provides legitimacy to information” is troubling, particularly because that’s what I perceive many of the organizations in the previous chart above as doing (e.g., USPSTF, The Cochrane Collaboration). The authors offer other organizations to consider:

In Washington state, the Health Technology Assessment Program was created by statute in 2006 to consider safety, clinical effectiveness, and cost–effectiveness in making coverage decisions for the state’s Medicaid, workers’ compensation program and the public employee self-funded plan [7]. More recently, the New England Comparative Effectiveness Public Advisory Council was formed to provide independent guidance on how information from Agency for Healthcare Research and Quality evidence reviews supplemented with budget impact and cost–effectiveness information can best be used by public and private payers, clinicians and patients [8]. The Washington state program has legal authority to set policy, while the New England Comparative Effectiveness Public Advisory Council does not make specific coverage recommendations but serves as an independent, objective source of interpretation and guidance. Medicaid policy makers in other states may be interested in having external validation of their own conclusions or additional sources of trusted information they can apply to their policy making.

Between the American Recovery and Reinvestment Act of 2009, the Patient-Centered Outcomes Research Institute (PCORI), the National Institute of Health, the Veterans Health Administration, and other organizations and agencies, billions of dollars have been spent on comparative effectiveness research (CER), with more to come. That’s the input. The study by Joel Weissman and colleagues tells us a little bit about the output and how it’s perceived and used.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.

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Written by James Buehler, M.D., Philadelphia Health Commissioner

I authored a commentary that is part of the eGEMs and Frontiers series on information needs and the role of informatics in public health while I was a university faculty member, but I am writing now as the health commissioner for Philadelphia, the fifth largest city in the United States. As I read these papers, I was struck by how much easier it is to envision the future we would like to occupy than it will be to get there, by the number of things the authors of these papers advise that health departments should be doing, and by the challenges in balancing attention to the day-to-day situations versus attention to cultivating opportunities and capacities that will assure our future success. It is exciting to think about new sources and ways of using information that will arise from the expanding uses of electronic health records (EHRs) and electronic information exchange, but it is daunting to consider the hurdles that must be overcome to fulfill that promise, especially for public health agencies, as several authors noted.

Yet, this is a dynamic time to be working in public health, especially in a place like Philadelphia where our health department operates a network of primary care clinics that have installed an EHR system, so we can now see the health care and public health sides of population heath “up close and personal.”

In addition, Philadelphia is privileged to be surrounded by academic medical centers, a robust network of federally-qualified health centers, and partners from multiple sectors working to promote health in our neighborhoods; and we live in a state where Medicaid expansion is under way and Medicaid managed care providers and health care systems are testing new ways to engage their patients.

Many authors in the series commented about differing perceptions of the term “population health,” but a key unifying reality is that our health is shaped not just by the health care we receive, but also by our families, communities, and opportunities. In a city like Philadelphia, which has the highest poverty rate among the nation’s largest cities, those opportunities are often constrained by economic forces that adversely affect jobs and schools. This is not news, of course, but the population health provisions of the Affordable Care Act (ACA) and the federal program to expand the use of EHRs create new requirements and incentives for health care providers to address health care-community connections. They also create new opportunities for public health agencies to play a leadership role in building connections between health care and community services. A critical example is the ACA requirement that not-for-profit hospitals conduct periodic community health needs assessments, including recently updated guidance that they consult with at least one governmental public health agency. Like many health departments, ours has developed a city-wide health assessment and a community health improvement plan, both requirements for public health accreditation. We have an opportunity to point hospitals to that plan as they develop community benefit programs that must be informed by their needs assessments.

So where do we go from here? Personally, I plan to keep this set of papers close at hand as a reminder of the new opportunities and challenges now facing public health. The Philadelphia Department of Public Health will not be able to do everything the authors envision, but the authors have provided a valuable framework for navigating in our new world.

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In April 2014, House Energy and Commerce Chairman Fred Upton (R-MI) and Congresswoman Diana DeGette (C-CO) launched a cross-country series of roundtable discussions with stakeholders of all background to discuss medical innovation and, in particular, how to accelerate discovery and bring cures to patients, faster. The effort was dubbed “21st Century Cures,” and it quickly gained widespread bipartisan support.

The listening tour has informed a sizable piece of legislation encompassing provisions that will affect the National Institutes of Health (NIH), the Food and Drug Administration (FDA), and the Centers for Medicare and Medicaid Services. It has moved swiftly through the Energy and Commerce Committee, passing the full committee by an almost unprecedented unanimous vote before Memorial Day. Chairman Upton remains committed to enacting the bill before the end of this calendar year–earning praise from former Speaker Newt Gingrich and author of The Emperor of All Maladies Dr. Siddartha Mukherjee, among many others–but the bill must overcome several challenges before it makes it to the president’s desk.

First, there are procedural complications. Due to the breadth of the bill, multiple committees share jurisdiction over it. The Appropriations, Ways & Means, Budget, and Rules Committees will need to consider the bill, or waive their jurisdiction, before it can be brought to the House floor. The bill has been referred to the Ways & Means Committee, and if it and other committees consider the bill, it will push a floor vote in the House past Chairman Upton’s goal of the end of June.

The Senate is another obstacle on the way to final passage. Health, Education, Labor and Pensions (HELP) Committee Chairman Lamar Alexander (R-TN) and Senator Richard Burr (R-NC) have launched their own initiative directed at accelerating cures, titled “Innovations for Healthier Americans.” In public meetings, Senator Burr has stated that the Senate will consider its own bill and that the end of 2016 is a more realistic goal for its final passage. Chairman Upton himself concedes that moving his bill whole cloth through the upper chamber will be a challenge.

Finally, the substance of the bill itself may prove to be a hurdle. Despite the initial fanfare for the bill, as the 21st Century Cures Act evolves and stakeholders dig deeper into the details, they’re finding more they don’t like. For example, advocates remain wary of several provisions in the bill, including a new mandatory research funding stream called the Innovation Fund (see CQ coverage here, subscription required). The Fund would provide NIH $10 billion over five years to supplement the base budget as appropriated by Congress and “support biomedical research through the funding of basic, translational, and clinical research;” health services, behavioral, and social science research are conspicuously omitted from the list of research eligible for this funding. Within these categories, the Fund is earmarked for very specific types of projects, including emerging scientist initiated research and a new “Accelerating Advancement Program.” And of course, the money is not without its strings. Many in the community fear that Section 1022, “Increasing Accountability at the NIH,” would open the door for increased politicization of research funded by the NIH, as it requires Institute and Center directors to sign off on all research grants awarded by their respective Institutes.

Most notably, the Innovation Fund is not permanent. Advocates are concerned that  the agency will face a funding cliff in five years when Innovation Fund expires, similar to the cliff following the expiration of the American Recovery and Reinvestment Act (ARRA). There is also the very real risk that the Innovation Fund will follow the path of the Prevention and Public Health Fund and will be used to supplant rather than supplement the agency’s current base funding.

Beyond the provisions related to discovery, experts have expressed concerns about the “development” provisions that would roll back regulations governing drug and device approval and the impact on patient safety (see New England Journal of Medicine commentary), as well as the “delivery” provisions that relate to interoperability (see “Life as a Healthcare CIO” blog).

There are some provisions in the NIH portion of the bill that could benefit health services research, specifically in the realm of data. For example, the bill would allow the NIH Director to require grantees, on a case-by-case basis, to share the data they collect in NIH funded research and require the NIH to standardize certain patient inclusion criteria. It would also instruct NIH and FDA to enter into a collaborative a Clinical Trial Data System Agreement to implement a system to make de-identified clinical trial data from qualified clinical trials available for purposes of conducting further research. The bill also attempts to address the difficulty government scientists face in trying to attend scientific conferences, though arguably not forcefully enough.

AcademyHealth has provided input on the Cures initiative (see here and here) and is keeping a watchful eye on the legislation as it progresses in both chambers. We will continue to urge lawmakers to support the full continuum of health research, including health services research, and will keep you apprised of our activities and new developments.

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