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From the President

Making the case for funding health services research

From the November 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Christine K. Cassel, FACP

The combination of the market takeover of health care and the American public's apparent desire to reduce government programs is threatening to severely impair medical research and advances in patient care.

Since World War II, the United States has led the world in medical research, helping to prevent disease and improve quality of life. Even now, with revolutionary developments in genetics and approaches to treatment, we are on the verge of making enormous breakthroughs in the treatment of chronic illnesses such as diabetes, Alzheimer's disease and cancer.

Because of the high cost of health care, however, we are at risk of turning our backs on these advances. If we do not create a fair mechanism to fund research, these new treatments won't be available. At a time when we are spending 14% of the gross national product on health care, it is penny-wise and pound-foolish not to invest aggressively in research.

The biomedical community has been largely concerned with cuts to basic and clinical biological research, but funding for health services research, which is sometimes called "outcomes research," is also at risk. While advances in biological science are important, the science of population-based health is also critical because it allows us to evaluate new treatments and set priorities for clinical care.

Until recently, the United States has not had an effective approach to evaluating new medical treatments before they are widely used, a factor that has contributed to the high costs of health care. As we develop medical interventions, we need to ensure that their cost effectiveness is known so that we can provide the most appropriate intervention to as many people as possible.

It is through outcomes research, for example, that we have learned that annual chest X-rays do not save lives, and that breast cancer patients who do not have radical surgery often fare better than those who undergo radical mastectomies. Only by studying the outcomes of medical interventions in a systematic way can we can acquire this knowledge and at the same time develop new understandings of biology.

Saluting the AHCPR

But these kinds of studies are costly. Although they don't involve large laboratories and experimental animals, they do involve large-scale clinical trials and sophisticated approaches to evaluate patients' quality of life and functional status. A number of scientists, many of them internal medicine experts, have devoted their entire careers to outcomes studies and health services research.

That's why so many of us greeted the creation of the Agency for Health Care Policy and Research (AHCPR) with excitement. The agency's mission was to study outcomes and develop evidence-based guidelines for practice. Even though the AHCPR has received little funding by government standards—$143.7 million in fiscal year 1997—it has already made major contributions to our understanding of effective treatments for everything from cataracts to joint replacement. The agency also has issued major influential statements on topics such as pain treatment, congestive heart failure and urinary incontinence.

Unfortunately, the AHCPR became a poorly understood political football in Congress. New members who do not understand the history leading up to the agency have come to see it as just another example of government intrusion in health care. Nothing could be further from the truth. The public needs the kind of information the AHCPR produces to adequately evaluate health plans. Outcomes studies and health services research are especially important in Medicare because the cost of care is so high and because older people are more susceptible to the side effects of treatments. Clinical decisions need to be made carefully because of multiple co-existing chronic illnesses, and outcomes research can aid in that decision-making process.

Many policy makers think that the private sector, not the government, will pay for this research. They are wrong for several reasons. For one, the private sector is less likely to conduct studies related to quality of life and will focus only on areas that offer immediate savings. In addition, privately funded research results are often proprietary and not made available to the public. Publicly supported research, on the other hand, is available to all patients, families and health care providers.

Act now

As a new Congress comes into session after this month's elections, we should renew our efforts to educate members who are not familiar with AHCPR and its mission. We should also ask our colleagues to support the mission of the AHCPR—and its expansion. Risa J. Lavizzo-Mourey, FACP, an ACP Regent and former deputy director of AHCPR, has pointed to the near consensus among physicians that all clinicians need health services research conducted without interference from proprietary interests. Like a commission on medical ethics, such research needs to be independent, and its mission needs to be in the public domain.

It is also important that all stakeholders—not just the government—contribute to this research. The private sector and proprietary investor-owned health plans that dominate health care delivery should invest in this research, as they will ultimately benefit from it. "All-payer" proposals to pay for biomedical research are perhaps most appropriate for supporting health services and outcomes research.

Finally, it is only with evidence-based approaches to medical decisions that physicians can effectively take leadership roles in health care delivery. Understanding cost-effectiveness with the emphasis on effectiveness and not merely costs should be every doctor's guiding interest, whether in primary care, subspecialty medicine or administration. Good cost-effectiveness research can help us regain and retain physician leadership and autonomy in patient care. In order to achieve this goal and demonstrate our responsibility in this area to the public, we must view cost effectiveness as a useful tool to be employed for our patients' benefit, not something forced upon us by a bureaucracy concerned only with the bottom line.

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