On March 26, 1997, John M. Eisenberg, M.D., a former president of the Society of General Internal Medicine (SGIM), was appointed as Administrator of the Agency for Health Care Policy and Research (AHCPR). SGIM staff subsequently interviewed him to determine his perspective on the mission of AHCPR and the status of a number of specific programs funded by the Agency. Highlights of the interview were published in the SGIM Forum (Vol. 20, No. 10, Oct. 1997), and they are presented here with the permission of SGIM.
SGIM: AHCPR has had a rocky course over the past 2 years. Some of this has been due to misunderstandings by policymakers and our elected officials about the mission of AHCPR. From your perspective, what were some of the most important misunderstandings about the Agency's mission? How have these been addressed, and how might they further be addressed by SGIM members?
Eisenberg: AHCPR's greatest challenge over the last 2 years has been creating public awareness of the importance of health services research and the value that AHCPR provides. Unlike biomedical research, the mission of health services research is a difficult concept to convey to policymakers and the public. For example, I think most people understand that the fundamental research carried out by biomedical researchers may contribute to the development of new treatments for feared diseases. It has seemed to be more difficult to explain effectively how health services research will ensure that the patients who need treatment get it in a high quality, appropriate, and timely manner.
Those of us in primary care and in health services research have also not helped policymakers become sufficiently familiar with the importance of health services research in understanding and improving the health care marketplace, including the changes caused by the increase in the tools and methods of managed care. The increased demand today by consumers, purchasers, clinicians, plans, and others for information on outcomes, cost, quality, and satisfaction has helped raise awareness of the importance of health services research, but there is still much more work to be done by all of us. We need to make our research relevant to the needs of those who could use it to guide public policy, to manage systems of care, and to enhance clinical decisionmaking.
I also think there were some fundamental misunderstandings about AHCPR's guidelines program. One of the most significant was the view taken by some policymakers that AHCPR was "The Guideline Agency," when in fact, guidelines represented less than 10 percent of AHCPR's budget. The Agency did raise the bar by supporting guidelines built on evidence by multidisciplinary groups, and we plan to continue to gather the evidence needed to improve practice.
How can SGIM help to enhance future understanding? Researchers can conduct studies that are methodologically sophisticated and carefully designed, but relevant to decisions being made today and those that will be made in the future. Clinicians can learn to use health care research to enhance the effectiveness of their own practices.
SGIM: As you are well aware from your previous roles as an investigator, General Medicine Division Chief, and Department Chair, supporting health services researchers individually and creating and sustaining multidisciplinary health services research teams are critical to maintaining, and hopefully growing, our country's health services research efforts. As opposed to the National Institutes of Health (NIH), which has a variety of mechanisms for supporting investigators at various phases of their careers, AHCPR has had essentially no such support. Are there any plans for changing this? Other than topic-oriented large projects such as Patient Outcomes Research Teams (PORTs), are there any mechanisms envisioned that could help support interdisciplinary teams?
Eisenberg: AHCPR has worked in the past to build capacity for health services research, and we plan to continue to expand our efforts. Through our dissertation grants program and the National Research Service Award (NRSA) grants, we already are nurturing the careers of new investigators. We also plan to work with the research community to create centers of excellence where teams of established researchers can do state-of-the-art work, and at the same time enhance the career development of new researchers. AHCPR has done this with our PORTs and our 12 Evidence-based Practice Centers will expand these opportunities. We also hope to follow the NIH model and invite some young investigators to spend time training at AHCPR learning about health care research.
SGIM: Near the beginning of this year, there were plans to reduce AHCPR support so that NRSA Health Services Research Training Grants would be cut on the order of 20 percent. Ironically, this came on the heels of the recommendation by the Institute of Medicine that the capacity for health services research in this country should be nearly doubled. Are these planned cuts still in the works or, on the contrary, are there plans to increase rather than decrease this training support?
Eisenberg: Our funding for NRSA comes from a pool of funds set aside by the Public Health Services Act (HRSA). Under the Act, AHCPR and the Health Resources and Services Administration receive 1 percent of this fund which is administered by NIH. Our funding for NRSA in Fiscal Year 1998 will depend on the amount set aside in the budget.
We are also looking to develop innovative strategies for increasing our opportunities for training of young investigators. AHCPR recently issued a grant announcement inviting applications for incentive awards for innovative approaches to health services research training that are responsive to the research and analytic needs of the evolving health care delivery system. We expect to award $1 million in Fiscal Year 1998, depending on our funding level.
SGIM: Although the Medical Expenditures Panel Survey (MEPS) may well provide useful information for researchers and policymakers alike, there is great concern that its funding has come at the expense of investigator-initiated research. Indeed, while the MEPS project has grown, investigator-initiated research has fallen dramatically with few new grants. What can you tell SGIM members about near- and long-term plans in this regard?
Eisenberg: I have been impressed at how powerful and valuable a tool MEPS is for investigator-initiated research on health care access and utilization. SGIM members who have used its predecessor, the National Medical Expenditure Survey, will be very pleased by the enhancements to the survey. I would urge all SGIM members to take a look at MEPS and the data it provides. It is in the public domain, available free of charge to anyone who wants to use the data. Therefore, investigators have access to nationally representative data on health care use, expenditures, source of payment, and insurance coverage for the U.S. civilian noninstitutionalized population just by downloading files from AHCPR's Web site or ordering CD-ROMs from AHCPR's Publications Clearinghouse (1-800-358-9295).
SGIM: Even aside from the MEPS, there is great concern among health services researchers that an increasing fraction of AHCPR's funding is going to contract-related and RFA-related research rather than to investigator-initiated work. What will be the upcoming trends with regard to the support of investigator-initiated research?
Eisenberg: Contracts and requests for applications (RFAs) seem to be a large part of our budget because our recent financial situation has required that we use funds that could have gone to investigator-initiated research to target research questions we felt were vital to the health care system. However, we have made sure that the RFAs we sponsor have enough flexibility to allow investigators to initiate proposals within the topic of the RFA.
I am personally committed to fostering innovation from the field through investigator-initiated research. Like any funding organization, we are working to strike a balance between targeted research funding and investigator-initiated research. Our limited budget challenges us to fulfill the responsibilities given the Agency and to support more grants, and this is just what I intend to do. We will be taking a critical look at that balance and reviewing the criteria we use to determine when we target funding to a particular area. As part of this effort, we will step up our efforts to fund partners to share in the funding of targeted research.
SGIM: There has been a growing sense that the review of grants at AHCPR has not had the adherence to study section ratings that had characterized the Public Health Service (PHS) system in general, and NIH in specific. Can you comment on this?
Eisenberg: The recommendations of study sections are advisory, but we will continue to pay careful attention to their advice, especially concerning methodologic and design issues. While reviews of study sections are the primary factor in deciding what to fund, they are not the only factor. The timeliness and relevance of applications to the Agency's mission and emphasis must also be taken into consideration.
SGIM: What are your general thoughts about the direction of health services research in the coming 5 to 10 years?
Eisenberg: Health services research needs to continue to pursue good research on what works and does not work in the health care system. I mean what works not only in clinical services, but also in the organization and financing of health care. We also need to understand the factors that can influence the quality of medical care. But good research is no longer enough—it must be linked with action. The changes to the health care system make it imperative that our research be relevant to national health care priorities and applicable to the delivery of health services.
The work of health services researchers is not done when they receive letters from journal editors letting them know that their articles have been accepted for publication. If we do not translate our research into an understandable language, disseminate our findings, and ensure that they are applied, the public may not benefit from work funded by AHCPR and other funding organizations.
AHCPR and health services researchers face an important challenge as we enter the new century. The research they are conducting now will yield the findings, tools, and strategies that the health care system will use several years from now. Therefore, health services researchers need to set research agendas that anticipate the health problems and priorities of the future. That takes foresight, knowledge, and wisdom as well as methodological skills, but that is what it takes to be an outstanding health services researcher.
We also must strengthen our efforts to ensure that consumers are empowered with information. The ultimate success of our growing market-based health system is predicated on informed consumers who can make choices that help them realize their preferences. Now like never before, health services researchers must emphasize the development and dissemination of information that helps consumers make better, more knowledgeable health care decisions based on methodologically sound, carefully conducted research.
SGIM: What would you do if you had $3 billion to spend each year at AHCPR?
Eisenberg: I would be happy to answer that question even at an order of magnitude lower. Whatever the figure, we all want to focus on capacity building in health care research, career development, investigator-initiated awards, funding centers of excellence, building tools for improving care, and helping markets work more effectively.
Internet Citation:
Interview with John M. Eisenberg, M.D. Adapted from SGIM Forum (Vol. 20, No.10, Oct 1997). Agency for Health Care Policy and Research, Rockville, MD, May 1998. http://www.ahrq.gov/news/jme-sgim.htm
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