The Agency for Healthcare Research and Quality (AHRQ) is on the chopping block — again — and supporters are gearing up for what could be their biggest fight yet to save the little-known agency.
In his fiscal year 2018 budget proposal, President Donald Trump has proposed eliminating AHRQ’s funding and folding the agency into the National Institutes of Health, which itself is facing a proposed 18% cut to its current $31.7 billion budget, and a requested $1.2 billion cut in FY 2017 funding. Those in favor of the merger say AHRQ’s work duplicates work that NIH does. But its supporters say it plays a unique and essential role in healthcare delivery.
Reducing central line infections
Created in 1989, AHRQ’s mission is to produce evidence that ensures that healthcare is delivered in the safest, most effective and efficient means possible to patients.
One of AHRQ’s biggest successes has been in reducing hospital-acquired conditions, particularly central line infections. Between 2010 and 2015, the number of HACs dropped by 21% as a result of AHRQ research and protocols. That resulted in 3 million fewer people being harmed and 125,000 lives saved, at a cost savings of $28 billion, according to the agency.
Reducing central line infections, the deadliest of HACs, has been a major focus for AHRQ. From a $500,000 research grant, the agency gained evidence on how physicians and other clinicians could do a better job monitoring central lines and preventing infections. Protocols were developed and have been implemented in hospitals across the country. In the first 18 months in Michigan, where the program was piloted, hospitals saved 1,500 lives and nearly $100 million — pretty good for return on investment.
The agency has also funded evidence-based research on how to reduce catheter-associated urinary tract infections and how to reduce falls and pressure ulcers.
“It’s critically important for those who run healthcare delivery organizations to have a set of research that can inform and empower decisionmaking to push safety and quality forward continuously,” Nancy Foster, vice president for quality and patient safety at the American Hospital Association, told Healthcare Dive.
Putting the healthcare puzzle together
Leah Binder, president and CEO of Leapfrog Group, says AHRQ is one of the best little agencies in Washington and a bargain for taxpayers. “We have the largest healthcare system in human history, and this is the one agency that tries to put all the pieces together so we can manage it well.”
The U.S. spends nearly $3 trillion on healthcare annually, of which about 2% goes toward health research. AHRQ’s budget is less than 1% of everything spent on health research and just 0.016% of all spending on healthcare, says Emily Holubowich, senior vice president at CRD Associates and the Washington representative for health services research society Academy Health.
“We’re spending a lot on developing new treatments, but then we’re falling short on that promise to patients because we’re not investing in how to make sure the patients are going to get the most out of those treatments,” she says. AHRQ is “filling out the remainder of that research continuum to be sure patients are getting the most bang for the buck.”
For FY 2017, Congress gave AHRQ $280 million in discretionary funding — down $54 million from 2016 and $84 million less than two years ago.
The last time that AHRQ faced a serious threat was during the FY 2016 budget negotiations, when the House Appropriations Committee voted to zero out the agency and its Senate counterpart voted for a 35% cut. Strong support from hospitals, physicians, patient advocates and other groups, as well as Obama administration, were able to shrink the funding loss to a still painful, but survivable, 8% cut.
This year could be even rougher.
“I expect that the support from the constituency groups will be there, but it doesn’t look like there will be any support from the White House, and I’m not sure about HHS,” says Richard Kronick, a former AHRQ director who is now with the University of California at San Diego. “It’s a much tougher environment than the last administration, which understood the value that the agency produced.”
Supporters of AHRQ say fusing the agency with NIH would be like trying to put a round peg in a square hole. Whereas NIH researches basic science and cures that will ultimately benefit patients, AHRQ cuts across a variety of sectors to focus on the actual delivery of care.
“If AHRQ were to be folded into NIH with an appropriate budget, there would be pros and cons,” says Kronick. On the plus side, AHRQ would be more protected. It would also be easier to coordinate health and safety research between the two agencies and get synergies from that work. However, that’s not what the president has proposed. “Moving AHRQ into NIH at the same time $1.2 billion is cut from NIH’s budget would be quite calamitous for the progress that has been made in making healthcare safer and improving the delivery of healthcare,” he says.
Holubowich agrees. “It’s hard to see how [NIH] could take on the mission, portfolio and activities of a new agency when its own budget is being cut by almost 20%,” she says. “Without a dedicated funding stream that’s sufficient to maintain the current capacity and without a dedicated place like a center or an institute, I think you would have to assume AHRQ’s portfolio will just wither on the vine.”
Preparing for battle
Meanwhile, the little agency keeps chugging along. Among its achievements are the Patient Safety Culture Assessment, a set of tools to help healthcare executives understand how those who work on the front lines of care delivery feel about their organizations’ support for patient safety, and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. AHRQ also created a set of evidence-based tools called TeamSTEPPS, aimed at enhancing patient outcomes by improving teamwork and communication among caregivers.
AHRQ is one of the few federal programs that is funded through discretionary funds, which makes it a likely target for lawmakers bent on reducing the federal budget. “You can’t cut service on the debt, and entitlements like Medicare and Medicaid are disasters if you touch those, so they go after discretionary funds, says Binder. “But it’s a very, very short-sighted cut because our healthcare system spends 18% of the GDP and a lot of it goes to waste and mismanagement of resources.”
Part of the problem is that not many people really understand what AHRQ does and its impact on healthcare. “It’s easy to understand that NIH is going to cure cancer or find a cure for Alzheimer’s disease or multiple sclerosis,” says Kronick. “AHRQ’s mission of producing evidence to make healthcare safer and improve the delivery of healthcare is harder to understand. And being a pretty small agency, it’s hard to get attention for that work.”
Supporters say they are in wait and see mode until the full budget is released in May, when details of Trump’s plan will become public.
This administration, with its orientation toward business, should grasp the value AHRQ provides, Binder says. “So I’m cautiously optimistic about that.”
“If there’s a silver lining, our field has been through this fight before, so we have a playbook,” says Holubowich. “The most critical aspect to preventing cuts to health services research is being at the table and educating lawmakers about its value and its contribution and why it’s so important.”