General Health Services Research and Health Care Technology
Assessment:

The budget request for general health services research and health care technology assessment, including dissemination and program support is $51 million in 1991. This includes $14.6 million in budget authority and $1 million to be transferred from the Medicare Trust Funds. In addition, $34.3 million is estimated to be available for evaluations under this program and $1.3 million is estimated to be available for National Research Service Awards

The $14.6 million in budget authority will continue to support approximately the 1990 level for research, and the dissemination of information deriving from research, on health care services and on the systems for the delivery of such services. Specific research includes such activities as health care services in rural areas, clinical practice, health care technologies, health care costs, productivity and market forces, primary care, long-term care, minorities and the disadvantaged, and medical liability.

As provided by section 926(b) of the Public Health Service Act $34.3 million is included for evaluative research in general health services and technology assessment in 1991. Of these funds, $20.5 million will support research on the delivery of health services to minorities and the disadvantaged, rural health research, primary care, health promotion and disease prevention, and medical liability. The other $13.8 million will continue support for the National Medical Expenditure Survey and the Hospital Studies Program.

The 1991 budget request includes transferring $1,037,000 from the Medicare Trust Funds, the same as 1990, for health care technology assessment activities.

Similar to 1990, the Agency for Health Care Policy and Research also will award an estimated $1.3 million for National Research Service Awards in 1991.

Acquired Immune Deficiency Syndrome/Human Immunodeficiency Virus:

The budget request includes $10.5 million for health services research on AIDS and HIV related illnesses, an increase of $2 million over 1990. The Agency for Health Care Policy and Research will support 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. The increase of $2 million will expand the AIDS Cost and Service Utilization Survey to address the health resource utilization of the asymptomatic population.

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.

Mr. NATCHER. Thank you, Dr. Mason.

Now if you will, tell us how long you have been the Assistant Secretary for Health.

Dr. MASON. I was sworn in April 19, 1989. It will be a year next month.

ORGANIZATIONAL CHANGES

Mr. NATCHER. Have you made any significant management or organizational changes in that time?

Dr. MASON. There have been a number of changes. For example, the new agency, the Agency for Health Care Policy and Research is being organized and brought together as a result of congressional activity late last year. We are also submitting for the Secretary's approval changes in our maternal and child health responsibilities that would create a separate bureau dealing with maternal and child health, infant mortality and problems that affect women.

As you know, we have been looking at our regional offices. There are 10 regions that come under the Department of Health and Human Services. We have been looking at their organizational status, the responsibilities of the regional health administrators and the delegations of authority for grants management.

We are evaluating the situation at this time.

Mr. NATCHER. What are your major objectives, Dr. Mason, for the Public Health Service for the coming year?

Dr. MASON. Our major objectives are, first of all, to support Secretary Louis W. Sullivan in his priority areas. Of the five that he has articulated so well, three are predominantly the responsibilities of the USPHS. They include: enhancing the capacity of the nation's biomedical establishment, strengthening health promotion and disease prevention and the targeting of services and resources to disadvantaged populations in the United States of America.

Under those three rubrics we are encompassing all the major responsibilities of the United States Public Health Service.

PHS EMPLOYMENT

Mr. NATCHER. For the record, if you will, supply a chart showing Public Health Service employment by agency from 1987 to 1991 and break out the AIDS staffing separately, if you will please. Dr. MASON. We will be delighted to do that, Mr. Chairman. [The information follows:]

Mr. NATCHER. Does your office determine the personnel ceilings for each of the agencies in the public service?

Dr. MASON. We do not specifically determine ceilings. We play a role in the budgeting process of identifying how many full-time equivalents are needed in each of the agencies. Then we make recommendations with regard to FTEs which are submitted to the Secretary of the Department.

They go forward to OMB and then are finalized in the President's budget. In our budget for the Public Health Service, the President has recommended an increase of 1,154 FTEs.

DIRECTOR OF NIH VACANCY

Mr. NATCHER. With the exception of the Director of NIH are all the top positions in the Public Health Service filled at this time? Dr. MASON. We are also in the process of recruiting for a Commissioner of the Food and Drug Administration. Acting Commissioner James Benson is handling it until we are able to make that appointment. In the new agency we have Dr. Jarrett Clinton, who is the Acting Administrator of the Agency for Health Care Policy and Research. A search will be undertaken to fill that position on a permanent basis.

Mr. NATCHER. How long has the position of Director at the National Institutes of Health been vacant?

Dr. MASON. Dr. James Wyngaarden announced his resignation during the summer and left approximately the first of August. So that position has been vacant about six months now.

Mr. NATCHER. If current recruiting efforts go smoothly, what is the earliest that we can expect to have a new director of the National Institutes of Health on board, Dr. Mason?

Dr. MASON. We are working very diligently to hire a new director. You are aware of the problems that we got into with regard to the so-called "litmus test." We have commissioned an advisory committee for the National Institutes of Health because we recognize that there are problems in the position of the Director of NIH. The job doesn't pay competitively with what a person can get in the private sector or academia. It probably pays one-quarter to a third of what most people are able to earn out there.

There are other problems with the position in terms of the responsibility for developing the nations biomedical care policy. So the advisory committee is assisting the Secretary and me in improving and strengthening that position.

Simultaneously, we have a group of research consultants that are working on the problem. They met two weeks ago and will be meeting again in two weeks. At that time we will again go over a list of promising individuals.

I think that Secretary Sullivan and President Bush are within six to eight weeks of announcing a new NIH Director.

Mr. NATCHER. The Secretary's review seems to focus on the problem of the independence and authority of the director. Is the issue that NIH is micro-managed from outside or that the Director does not have enough authority over the individual institutes?

Dr. MASON. That was discussed at some length. Specifically, the National Cancer Institute, which has probably more authority than

any of the other institutes, came up in the discussion of the advisory committee. One of the problems as well, and I really hesitate to mention this, is that I think Congress has micro-managed NIH a bit and deleted and had some negative effects upon the authority of the NIH director. They have created a whole group of institutes which makes it increasingly difficult to control. I think within my office, within the office of the Secretary, we can identify areas where we have tended to try to detract from the power of that position. We find there are a number of things that can be done to correct the situation.

Some will require legislative help. For instance, we will need to come back to Congress with regard to the salary problem. I think we need to work on all these problems. It is like the Pogo comic strip. We have met the enemy and they are us, all of us. I think we need to put a little more strength back into that position.

SUPPORT FOR NIH

Mr. NATCHER. Dr. Mason, as you well know, our subcommittee is not the authorizing committee as far as adding new institutes. If we had been in charge maybe they would not have added some of the institutes. I believe we have 13 now as far as the National Institutes of Health are concerned.

Dr. Mason, if anybody asks you, you tell them when I was first elected a Member of this committee we had $73,000,000 in the budget for NIH. Last year the figure was $7,576,000,000. If Lou Stokes and Silvio Conte and I and the other members of this subcommittee had our way, it would be $10,000,000,000.

So we have been following carefully on this subcommittee all of these matters. NIH has never had a better friend, Dr. Mason.

Dr. MASON. I think it has a lot of friends both in Congress and in the Executive Branch of government. This ought to be a very promising time for biomedical research in the United States.

It just has to be not only in the context of quality of life and the health of the American people but so that we can maintain our competitiveness in international markets, our balance of payment. We appreciate your support and the support of other members of this subcommittee with regard to this effort.

NIH GRANTS

Mr. NATCHER. Dr. Mason, this year NIH is facing a serious problem, as you know, because of the reduced number of new grants which, as you know, is down around 4600 compared to over 6200 several years ago.

This problem is largely the result of NIH's decision to lengthen grants which leaves less funds for competing awards. Doctor, given the cost of this decision, is this a good decision, one you support?

Dr. MASON. I support that decision. When we look at the total number of grants that will be funded in the 1991 budget for NIH it will go well above 20,000. This, I think, is significant. The numbers would have increased even more had we not funded grants for longer periods of time.

But we find in the context of the complexity of biomedical research, bio-technology, that often a grant can't be finished in two