From 1999 to 2000, researchers at the New York Academy of Medicine conducted a study of the history of the federal Agency for Health Care Policy and Research.
The agency has been a key federal office aimed at improving quality and effectiveness of health care, and its history and activities have been controversial. The study, which coincided with the 10th anniversary of the agency's inception, built on a 1991 study of the agency's origins by the project director, also funded by RWJF (ID# 017364).
The Project: For the study, project investigators conducted more than 100 interviews and reviewed documentary information, including congressional hearings, evaluations of the agency by federal and congressional agencies and commissions as well as by independent consultants and researchers, and other materials.
In the study, investigators reviewed the agency's effectiveness in reaching its three original goals:
- Funding to improve the scientific basis for medical practice. Earlier research results had found wide variations in health care practices around the country and inappropriate use of common surgical procedures.
- Addressing the health care cost problem, particularly in Medicare. The practice variations by physicians raised hopes in Congress for cost reductions.
- Securing adequate funding for health services research. This was the agenda of one of they agency's main promoters, the Association for Health Services Research.
The Commonwealth Fund also contributed $25,000 to the project.
- Investigators found that Agency for Health Care Policy and Research was most successful at meeting this last goal. Its creation established a new, high-profile federal office with several funding streams.
The agency attempted to reduce variation in medical practice by carrying out large multidisciplinary, multi-institutional projects that focused on patient outcomes of specific clinical problems. But it later abandoned this approach because it was expensive, descriptive rather than prescriptive, and had little impact on clinical practice.
To address cost savings, the agency developed practice guidelines for conditions such as low back pain, some of which were attacked by medical professionals. The investigators also observed that the goal of significant cost savings was unrealistic and receded as concern grew about health care quality.
In 1995, Congress considered eliminating the Agency for Health Care Policy and Research for several reasons. A new group of Republican legislators wanted to cut government programs, and the agency had worked closely on and was associated with President Clinton's failed health care reform effort. In addition, the agency had been accused of interfering with the practice of medicine through its practice guidelines.
The Agency for Health Care Policy and Research survived the threats, but these events conveyed several lessons, according to the study:
Having the word "policy" in its name put the Agency for Health Care Policy and Research at risk of being identified with unpopular health policies of any administration, according to the study.
- The value of engaging in activities that are important to those in the administration and Congress who affect the agency's resources.
- The need to make key constituencies aware of the agency's activities.
- The importance of avoiding activities that may generate negative political fallout.
In addition, the development and dissemination of practice guidelines would always carry a substantial risk of generating opposition from affected providers who might organize to oppose the agency's funding in the appropriations process.
In response to these lessons, 1999 federal legislation changed the Agency for Health Care Policy and Research's name to the Agency for Healthcare Research and Quality, dropping the word "policy" from its title. The legislation also eliminated references to practice guidelines and stated explicitly that the agency is not a regulatory body.