The Trump administration has proposed slashing the National Institutes of Health (NIH) budget, saying it is bloated with unnecessary expenses resulting in waste and abuse. It has also proposed to eliminate the independent status of the Agency for Healthcare Research and Quality (AHRQ) and absorb it into the NIH.
AHRQ is a little-known agency that focuses on improving health care quality and applying it to patient safety. It is one of the true unsung heroes of the federal government, providing vital scientific research that has helped reduce diseases and keep seniors safe for the past 20 years.
Its research has become more important in recent years as the Obama administration pushed value-based reimbursement arrangements tying payments to clinical quality. It's too early to know if Trump will move away from that focus. AHRQ remains focused on applied research examining the effectiveness and costs of clinical practices and how they impact different populations.
The agency has taken on some of the toughest and most controversial medical issues focusing particularly on how to prevent medication mistakes and infections and how to get patients ready to leave the hospital so they can avoid costly readmissions. Both of these obviously are critical to seniors.
AHRQ has also recently examined how to change prescribing of opioids, improve care for diabetics and looked into how to use telehealth to serve rural patients.
One of the reasons the Trump administration and House Republicans are targeting AHRQ is that the agency has been overshadowed by other more well-known agencies like the Centers for Disease and Control and Prevention, NIH, and the new Centers for Medicare and Medicaid Services Innovation Center, which was given a $1 billion budget under Obama to test changes in the delivery and financing of medical care.
The type and scope of research AHRQ has done is truly impressive as is its recognition of the importance of certain topics long before others are paying attention. For example, in 2003, the agency began work on antimicrobial stewardship in nursing homes, looking at what is the appropriate use of antimicrobials, including antibiotics, and how it improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms. It wasn't until 2015 that the CDC and the White House began to call attention to that issue in a very public way.
Since 2010, AHRQ's research and tools for medical providers have helped to produce a 21 percent reduction in hospital-acquired conditions like deadly bloodstream infections. That translates to 3 million fewer adverse medical events and savings of $28 billion. Dr. Richard Kronick, who directed the agency at that time and is now at the University of California, San Diego, told Stat the infection-prevention measures "resulted in 124,000 fewer people dying in hospitals because hospitals are safer places than they used to be."
AHRQ's effort to reduce hospital-acquired conditions include tool kits to help hospitals to help prevent bed sores, falls, urinary tract infections and medication mistakes. In 2001, Pronovost, the patient safety specialist at Johns Hopkins Medicine, developed a step-by-step checklist to prevent line infections in catheters inserted into a vein to supply a patient with nutrients and medicine. This checklist for intensive care providers, reminded doctors of the fundamentals when they inserted these lines including washing their hands with soap and wearing protective clothing like a sterile mask, hat, gown and gloves. Pronovost credits AHRQ with the early money that helped to disseminate the checklist and other prevention tips to medical personnel nationwide.
In 2001, 43,000 ICU patients in the U.S. had central-line associated bloodstream infections, which kill 12% to 25% of its patients and cost an average of $70,000 per patient. By 2009, central line-associated bloodstream infections in ICU patients in the U.S. had dropped to 18,000. Since then, those infections have dropped by as much as 80 percent in intensive care units in the U.S., according to a 2013 study. "These infections were a public health problem on par with breast and prostate cancer," Pronovost told Modern Healthcare. "Imagine the praises we'd be singing if someone knocked prostate cancer down by that much. We certainly wouldn't be saying, let's defund the agency that helped make that real."
Another area where AHRQ has been a leader has been on long-term care issues. It did a comprehensive study of long term care in 2011, comparing the effectiveness of institutional care versus home and community-based care. It also developed a way for consumers to compare the benefits and quality of Medicare managed care plans in their area: the Consumer Assessment of Health Plans Survey that can be found on the AHRQ's website https://www.ahrq.gov/cahps/index.html.
Efforts to Kill AHRQ
AHRQ has survived for many years with a huge target on its back because it takes a hard look at whether popular treatments actually help patients and are safe. Those careful examinations have run afoul of powerful constituencies, prompting lots of enemies. Since 2012, when House Republicans passed a measure to eliminate funding for AHRQ, which was not enacted, some lawmakers have tried to kill the agency or gut its funding.
Mix a charged political atmosphere, and the collision of science, health care, and research – and inevitable controversy follows. One of those firestorms happened in the 1990s when the agency looked at the usefulness of lower-back pain treatments. It issued guidelines that said, in most cases, less invasive interventions would eventually cause the pain to go away without the need for costly operations.
Not surprisingly, that didn't sit well with the lucrative back surgery industry of orthopedic and neurosurgeons, spinal groups and related medical personnel. The recommendations prompted serious heat from the North American Spine Society, whose members benefit directly from back surgeries. These doctors complained to Republican lawmakers, including key budget and appropriations members, who subsequently declared the agency's work to be inefficient, duplicative and proposed to eliminate its funding.
Repeated efforts to gut AHRQ's funding have become an annual event on Capitol Hill. But so far, they have not succeeded. Ophthalmologists also declared war after the agency issued a cataract guideline, and the pharmaceutical industry has also battled with AHRQ over a reduction in the use of new drugs.
Under the Trump budget proposed earlier this year, NIH would see its budget cut from its $32 billion down to $25.9 billion. Somehow, NIH is expected to absorb AHRQ despite the budget cuts.
The Trump administration argues the budget would "help focus resources on the highest priority research." In addition, the administration plans to cut an additional $1.2 billion from the current NIH budget and additionally has proposed across-the-board HHS spending cuts. NIH funds much of the nation's medical and health research, particularly research done by the country's universities.
AHRQ's funding is miniscule in terms of the overall trillion-dollar HHS budget, which includes funding of Medicare and Social Security among many other programs. AHRQ's estimated budget for fiscal 2017 is $433 million. Last year, senators tried to cut 35 percent of the agency's funding but met White House resistance. In the end, the Obama administration was forced to agree to an 8 percent budget cut.
Now, with Obama gone from office and former Rep. Tom Price, R-Ga., in charge at Health and Human Services, AHRQ's funding is once again under scrutiny both on Capitol Hill and in the Trump administration. At a recent House Appropriations Health Subcommittee hearing, Price defended the cuts as a way of pruning back wasted resources, without providing detailed specifics.
When Senate Appropriations Committee members proposed cutting $10 million from AHRQ's budget in 2016, a group of 168 medical and health organizations, calling themselves "friends of AHRQ" – including the Association of American Medical Colleges, the Mayo Clinic, American Heart Association and the American Hospital Association – wrote letters to House and Senate lawmakers, urging them to protect AHRQ from further cuts. "We understand lawmakers face difficult choices in funding myriad priorities with increasingly limited resources, but deep cuts to AHRQ in the current environment are pennywise and pound foolish," they argued.
In some places in the federal government, such as the Environmental Protection Agency, the Education Department, and the Energy Department among others, the Trump administration has installed people in charge who have previously been harsh critics of their agencies or have favored eliminating the agencies altogether. While Price has been a steadfast critic of HHS in his 12 years as a congressman, his opposition to NIH and AHRQ in particular are not viewed as malicious in his efforts to cut funding. Critics think he just doesn't understand the agency's role and how vital it really is.
But Price does have his own history with AHRQ. Earlier this year, stories surfaced about how Price has battled with AHRQ as a Georgia legislator. According to ProPublica, the Pulitzer-prize winning investigative reporting news organization, an aide to Price had sent several emails repeatedly pushing the agency to remove a critical drug study from its website that questioned the safety and efficacy of BiDil, a treatment for African-Americans suffering from heart failure.
The chief executive of Arbor Pharmaceuticals, the company that markets the drug, had given Price the maximum campaign contribution of $2,700. AHRQ ultimately kept the study on its website, but added a note: "This report is greater than 5 years old. Findings may be used for research purposes but should not be considered current."
While many fear the Trump’s plan to merge AHRQ into NIH, Andrew Bindman, who directed the agency at the end of Obama’s term, sees a possibility that it could result in a more financially-stable situation for the agency. If the move isn't a smokescreen to wipe out the agency altogether, Bindman argues in a recent Health Affairs Blog post, AHRQ "might gain some shelter against the attempts to have their work undermined through political action."
But the absorbing of AHRQ into NIH comes from the same President Trump, who during the campaign, called NIH, the nation's medical research agency, "terrible," and from his administration which is proposing to simultaneously cut the overall NIH budget. What happens is still to be determined.
[Also contributing to this story were Stat; Modern Healthcare; Pro Publica; Patient's Daily and Health Affairs Blog.]
Alan Schlein runs DeadlineOnline.com, an internet training and consulting firm. He is the author of the bestselling “Find It Online” books.