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STATEMENT OF DR. J. JARRETT CLINTON

Mr. Chairman and Members of the Committee:

I am pleased to appear before you today to discuss the Fiscal Year 1992 budget request for the Agency for Health Care Policy and Research.

The Agency for Health Care Policy and Research was created in December 1989 with enactment of the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239). Its purpose is to enhance the quality, appropriateness, and effectiveness of health care services and to improve access to that care. The Agency is the Federal Government's focal point for medical effectiveness and health services research, expanding on the work of its predecessor organization, the National Center for Health Services Research and Health Care Technology Assessment (NCHSR).

In carrying out the general duties of Title IX of the Public Health Service Act, the AHCPR is responsible for:

Developing a broad base of scientific research, methods, and data bases. This is done through funding extramural research grants, research contracts and by supporting intramural research activities.

Demonstrating and evaluating new ways to organize, finance, and direct health care services to improve the delivery, quality, access to, and outcomes of such services.

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Facilitating the development of clinically relevant guidelines for specific conditions and treatments and development of standardized measurements of quality care for use by physicians, nurses, allied health professionals, other health care practitioners, health educators and health care consumers.

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Assessing technologies being considered for reimbursement by Federally-funded programs.

Promoting the utilization of health services research findings and clinical guidelines through a systematic and broad-based program of information dissemination.

The Agency for Health Care Policy and Research is the newest agency of the Public Health Service yet it is built on a solid foundation. Over the last two decades, its predecessor, the NCHSR, supported research that has had a major effect on our health care system and on Federal policies. Many facets of today's health care system are structured and operate as a result of knowledge obtained from research sponsored by this organization. For example, our research provided the foundation for the Medicare DRG payment system and the Rural Health Clinics Act. The breadth and scope of past research activities have positioned the Agency to move quickly and effectively in the new directions mandated by Congress and those identified by the Secretary of the Department of Health and Human Services in his FY 1991 - FY 1992 Program Directions.

The Fiscal Year (FY) 1992 budget request for the Agency for Health Care Policy and Research is $122,000,000 in total obligations. This represents an increase of $7 million or 6 percent over 1991 obligations. The Agency's FY 1992 budget request is comprised of the following sources of funds: an appropriation from the general funds of the Treasury of $34,283,000; an appropriation from the Medicare Trust Funds, pursuant to Section 1142(i) of the Social Security Act, of $36,723,000; reimbursement from the Medicare Trust Funds for health care technology assessment, $1,050,000; and 40 percent of the maximum amount authorized for evaluations under section 2611 of the Public Health Service Act, pursuant to section 926(b) of said Act, estimated to be $49,944 ,000.

General Health Services Research and Health Care Technology
Assessment:

The budget request for general health services research and health care technology assessment is $56,723,000 in 1992. This includes $16,129,000 in budget authority, $1,050,000 to be transferred from the Medicare Trust Funds, and an additional $39,544,000 from PHS 1% evaluation funds to be allocated for evaluative research under this program. The 1992 request includes an increase of $6,591,000, or 13%, over the FY 1991 level of $50,132,000.

The 1992 request will provide for continued support of research on health care services and on the systems for the delivery of such services and the dissemination of information derived from such research. Specific research addresses such areas as health care services in rural areas, clinical practice, health care technologies, health care costs, managed care, long-term care, health services delivery for minorities and the disadvantaged, and medical liability.

The 1992 budget request for general health services research and technology assessment includes $10,800,000 for health services research on HIV/AIDS related illnesses. This is an increase of $548,000 over 1991. The Agency will convene a panel in FY 1991 - FY 1992 to develop HIV clinical guidelines. Also, the Agency will continue support of its AIDS Cost and Service Utilization Survey (ACSUS) to assess the health resource utilization of both the symptomatic and asymptomatic population. The Agency will support new research to study the availability, cost, and utilization of services for different HIV risk groups, populations, geographic areas, and stages of illness and treatment modalities.

As provided by section 926(b) of the Public Health Service Act, $39,544 ,000 is included for evaluative research in general health services and technology assessment in 1992. of these funds, $26,100,000 will support research in priority areas including such issues as medical liability and primary care. Activities under the broad topic of primary care include the delivery of health services to minorities and the disadvantaged, rural health research, infant mortality, health promotion and disease prevention. The remaining $13,444,000 from 1% evaluation funds will continue support for the National Medical Expenditure Survey and the Provider Studies Program.

The 1992 budget request includes transferring $1,050,000 from the Medicare Trust Funds, for health care technology assessment activities undertaken at the request of the Health Care Financing

This is an increase of $38,000 over the 1991 level

Administration. of $1,012,000.

Medical Treatment Effectiveness:

The budget request includes $62,947,000 for the Medical Treatment Effectiveness Program. This request will enable the Agency to maintain the FY 1991 level of effort for this program. of the $62,947,000 requested, $36,723,000 will be appropriated from the Medicare Trust Funds; $15,824,000 will come from the general fund of the Treasury; and an additional $10,400,000 from PHS 1% evaluation funds will be allocated for evaluative research under this program.

The Medical Treatment Effectiveness Program is a continuing high priority to improve the effectiveness and appropriateness of health care services and procedures through a better understanding of the effects of health care practices on patient outcomes. The ultimate goal of the program is to provide information to patients and practitioners that will improve the health of our population and optimize utilization of scarce health care resources.

This is a Departmental program which involves formal collaboration with other agencies of the Public Health Service and the Health Care Financing Administration. Major components of the program are outcomes research and data development, guidelines development, and dissemination and assimilation of findings.

More specifically, the program supports the development of scientific knowledge about patient outcomes through the development of methodologies to support outcomes research; the development and supplementation of databases to support outcomes research; the support and conduct of outcomes research; the dissemination of information derived from outcomes research; and the development and periodic review and updating of clinically relevant guidelines, standards, performance measures and review criteria.

The $62,947,000 requested for this important initiative will continue the momentum given to the program in 1991. For example, in FY 1992 the AHCPR will continue to support Patient outcome Research Teams (PORTS). These multidisciplinary teams identify and analyze the outcomes and costs of alternative practice patterns for a specific condition; determine the best strategy for treatment or clinical management of this condition; and develop and test methods for reducing inappropriate variations in practice patterns. They also evaluate the effects of disseminating the findings and recommending changes to these practice patters. In 1991, PORTS are addressing the following issues:

myocardial infarction
cataracts
low back pain
total knee replacement
hip fracture
use of cesarean section

benign prostatic hypertrophy
chronic ischemic heart disease
pneumonia
biliary tract disease
diabetes

Also, in FY 1992 AHCPR will continue to facilitate and develop clinical guidelines. Currently seven panels have been convened by AHCPR to develop guidelines for:

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Prediction, prevention, and early treatment of pressure sores in adults

Urinary incontinence in the adult

In addition, in FY 1991 the AHCPR will constitute a panel on HIV clinical guideline development.

Program Support:

The FY 1992 budget request includes $2,330,000 for Program Support. This request will support the overall direction and management of the Agency for Health Care Policy and Research. This includes the formulation of policies and program objectives for the Agency; program planning and evaluation; grants and contracts management; resource management; and administrative management and services activities.

Mr. Chairman and Members of the Committee, I will be pleased to answer any questions you may have on the specifics of this budget request.

FISCAL YEAR 1992 FUNDING LEVEL REQUEST Senator HARKIN. Dr. Clinton, I have really two questions that I want to discuss with you, and then the rest we will submit for the record.

First, on the medical treatment effectiveness, the outcomes research level funding from last year, is this adequate to really keep up with the medical treatment effectiveness research? We have had a couple of years of big increases, and now it has leveled off. Why have we leveled that off? Why has your request leveled off there?

Dr. CLINTON. I think the constrained resources for all of us requires us to make several difficult decisions. While the Medical Treatment Effectiveness Program was certainly part of the energy and creation of the new agency, we became concerned that it was overshadowing the important fundamental health systems and health services research that is also under the jurisdiction of the Agency for Health Care Policy and Research.

Our primary objective this year in presenting a budget within those constraints was to bring a rebalance to the general health services research program. That had to be at some expense within our total agency budget, and we chose then to raise general health services research, holding the Medical Treatment Effectiveness Program at approximately

last year's level.

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I think the magnitude of work underway can without any question be sustained with that level of funding. It will make it not as vigorous in growth as it was in the first year, but that is to be understood. We are trying to accomplish a balanced program within the agency rather than focus on simply one component of the agency's required work.

NONTRADITIONAL HEALTH CARE

Senator HARKIN. Second and last question, you talked about investigating and researching alternate methods and means of medical delivery services, using different methods of delivering services. Let me ask you a more fundamental question.

When are we going to investigate nontraditional methods of medical treatment? You have a big budget here for $122 million, of which the total for health services, research, and technology assessment is $56.7 million.

What are we doing? Are you doing anything to investigate nontraditional medical treatments?

Dr. CLINTON. Could you give an example of what you mean by nontraditional health care?

Senator HARKIN. Sure. Different forms of treating cancer, for example; different methods for Lyme disease is another one. I am thinking back many years ago when acupuncture was looked upon as voodoo medicine, and we found out it actually worked. I think it is, if not widely, at least somewhat widely used in the United States and other countries around the world.

There are many reports from different areas that I have read. People have talked to me about how they have taken a different approach to perhaps curing Lyme disease or cancer or other things. They have said that it works. I find that there seems to be a reticence on the part of the medical community to not only accept but to at least objectively look at these. It is sort of considered, well, quackery. The medical community treats cancer this way, and that way is quackery.

I am wondering if you are looking at some of these. I mean you know as well as I do that there are a lot of different approaches that people are taking. Dr. CLINTON. I understand what you mean now.

Senator HARKIN. I read a book a couple of years ago about an individual in Pennsylvania who had cancer who was told he had not much of a chance and decided to take matters into his own hands. He was not a doctor, but he was involved in health care. He decided to treat it differently. His was a completely different approach, and yet he is alive and well today and cured of cancer.

What is being done to really look into these to see if there is anything there rather than just dismissing it as a quirk, something that is unexplainable and that type of thing?

Dr. CLINTON. There are two aspects to that, Mr. Chairman. First of all, any investigator in the United States who wants to propose a scientific study about what works in medicine can submit that application to the Public Health Service. That is translated predominantly to the grants receival system of the National Institutes of Health.

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