Meeting Minutes, May 2022
Contents
Summary
Call to Order and Approval of November 17, 2021, Meeting Summary
Discussion of New Opportunities for AHRQ
Patient-Centered Outcomes Research Trust Fund
AHRQ’s Role in Healthcare Financing Research
Public Comment
Chair's Wrap-Up and Final NAC Input
Adjournment
Summary
NAC Members Present
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital (NAC Chair)
Andrew D. Auerbach, M.D., M.P.H., University of San Francisco
Melinda B. Buntin, Ph.D., Vanderbilt University School of Medicine
Caroline Carney, M.D., M.Sc., Magellan Health
Susan Edgman-Levitan, P.A., Massachusetts General Hospital
Catherine H. Ivory, Ph.D., R.N., Vanderbilt University School of Nursing
Mireille Jacobson, Ph.D., M.A., University of Southern California, Leonard Davis School of Gerontology
Omar Lateef, D.O., Rush University Medical Center
Hoangmai Huu Pham, M.D., M.P.H., Institute for Exceptional Care
Patrick S. Romano, M.D., M.P.H., University of California, Davis
David F. Schmitz, M.D., FAAFP, University of North Dakota
Joedrecka S. Brown Speights, M.D., Florida State University College of Medicine
Henry H. Ting, M.D., M.B.A., Delta Air Lines
Yanling Yu, Ph.D., Washington Advocates for Patient Safety
Ex Officio and Alternates
Michael Lauer, M.D., National Institutes of Health
Michelle Schreiber, M.D., Centers for Medicare & Medicaid Services (for Shari Ling)
AHRQ Staff Members Present
Robert Otto Valdez, Ph.D., M.H.S.A., Director
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends
David Meyers, M.D., FAAFP, Deputy Director
Mamatha S. Pancholi, M.S., Center for Delivery, Organization, and Markets
Karin Rhodes, M.D., M.S., Chief Implementation Officer, Office of the Director
Call to Order and Approval of November 17, 2021, Meeting Summary
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital (NAC Chair)
Dr. Asaf Bitton called the meeting to order at 10:02 a.m. (Eastern) and asked the NAC attendees to introduce themselves. He referred to the draft minutes of the previous NAC meeting (November 17, 2021) and asked for changes and approval. The NAC members voted unanimously to approve the November minutes with no changes. Dr. Bitton reviewed the day’s agenda and introduced AHRQ’s new director, Robert Otto Valdez, Ph.D., M.H.S.A.
Discussion of New Opportunities for AHRQ
Robert Otto Valdez, Ph.D., M.H.S.A., Director, AHRQ
Dr. Valdez presented his vision of the goals and opportunities for AHRQ. He stressed that the nation is attempting to emerge from the COVID pandemic, which has stressed healthcare systems. AHRQ’s role includes producing scientific evidence for ways to make healthcare safer, of higher quality, more accessible, more equitable, and more affordable. Achieving this mission requires partnerships and leveraging with government agencies, nongovernmental groups, and industry. AHRQ has been working with healthcare systems throughout the nation, where consolidation has occurred.
AHRQ aligns its work with the priorities of President Biden and is attempting to transform the system so that it better serves everyone. It is addressing issues such as racism, long-term persistent COVID, maternal healthcare, integrative behavioral care, and climate effects.
AHRQ’s general framework for improving the lives of patients includes an examination of the interaction between patient and health professional. The well-being of the professional is part of the care equation. AHRQ seeks to improve the experience for the professional, through health system research. It researches practice improvement and monitors changes in the healthcare system, using data and analytics strategies.
AHRQ partners with other agencies, including the Centers for Disease Control and Prevention, especially regarding environmental issues. It partners with the Food and Drug Administration to ensure that drugs and devices are safe for use and with the National Institutes of Health (NIH) to focus on biomedicine and cures. Dr. Valdez presented schemata of the elements of the U.S. healthcare system, featuring tools, knowledge, illness burden, and consumer behaviors.
The agency has programs for improving the organization and delivery of high-quality care. These include TeamSTEPPS (healthcare worker tools, activities, teams of professionals), the Consumer Assessment of Healthcare Providers and Systems (CAHPS—decision-making tools and information), and the Medical Expenditure Panel Survey (MEPS—data/evidence to support improvement efforts). AHRQ seeks to translate new biomedical discoveries into breakthrough therapeutic practices. Its Evidence-based Practice Center program plays an important role in this work. The agency recognizes the cycles of discovery and improvement.
Dr. Valdez reported that the President’s proposed AHRQ budget for 2023 features $415.9 million in discretionary funds and $111 million provided by the Patient-Centered Outcomes Research Trust Fund (PCORTF). New investments within the budget include $19 million for long-COVID care, $5 million for an all-player-claims database, $2 million for centers of excellence in telehealth implementation, and $7.4 million for a maternal healthcare initiative.
Dr. Valdez concluded his remarks by listing and proposing some important priorities: focusing the agency on the patient-health professional dyad, emphasizing knowledge generation and implementation of new therapies, cultivating relationships with system leaders and governance, expanding professional relationships, engaging social and behavioral scientists for system change, and supporting patients in care delivery.
Discussion
Hoangmai Pham, Ph.D., M.P.H., proposed that the agency display humility in dealing with the reach of healthcare services and a person’s health, recognizing the need to study nuances (and opportunities) in social effects and healthcare. For their own well-being, the healthcare professional must understand those nuances. Dr. Pham suggested that AHRQ could help these professionals obtain inputs from others outside the medical office to solve the patient’s problems. Home- and community-based services should also be considered as well as best practices and resources in the sectors. When professionals have a good socioeconomic perspective their assessment of patient needs will improve. The agency should seek and use proprietary data, which could provide insights into the socioeconomic facts, spending, and outcomes. Dr. Valdez agreed that AHRQ could help health systems move beyond the clinical building to reach out to local social services, leading eventually to improved care delivery.
Susan Edgman-Levitan, P.A., asked about the forthcoming efforts to address maternal healthcare. Dr. Valdez responded that AHRQ will study ways to improve the monitoring of maternal care. There is a need to understand failure, develop tools, and focus on patients and environmental issues.
Melinda Buntin, Ph.D., complimented AHRQ on taking a systems-view through the years. She suggested that AHRQ not focus on the patient–healthcare professional dyad but, rather, proceed with the systems view to improve healthcare delivery. AHRQ is a modest agency and should focus on its core mission, that is, addressing the manifest problems with healthcare systems, delivery, and quality. Dr. Valdez responded that the agency would not want to move away from the systems view and will maintain a healthcare delivery focus. It will seek to understand the context in which care takes place and go beyond the patient’s illness to study interactions with the care provider. A systems approach is required to answer the question, “How do we transmit the evidence back into the system?”
Joedrecka Brown Speights, M.D., applauded the initiative on maternal health. She stated that bias and disparities, as well as physician burnout, persist in systems. Community engagement is needed to improve the patient experience. In response, Dr. Valdez highlighted the need to conceptualize better patient-centered care. For example, consider the particular issue of bed- wetting and the need for the family team. We must develop a new normal, as in treating older patients.
Catherine Ivory, Ph.D., R.N., stressed the presence of systemic effects, for example, racism, the root of problems in maternal outcomes. There are disparities in maternal health outcomes. The field must respond to the evidence for factors such as birth setting and provider. Advanced practice nurses and midwives might be the best providers of maternal care. Also needed are new care models that involve all care team members, data standardization, and the ability to identify the proper individuals. Further, resources could be treated as therapies. Dr. Ivory encouraged AHRQ to consider working more with the Office of the National Coordinator for Health
Information Technology (with health information technology [IT] standards). Dr. Valdez added that the rise of IT use has created gaps in needed personnel.
Mareille Jacobson, Ph.D., M.A., stressed the importance of addressing insurance issues, particularly those faced by patients. Yanling Yu, Ph.D., added that safe care, informing patients, and the community surrounding the patient are also important considerations.
Omar Lateef, D.O., encouraged AHRQ to study the issue of systemization within the healthcare system, including uniformity in measurement of quality and standardization of definitions. David Schmitz, M.D., added access to care and rural maternal care to this list. AHRQ could study how quality connects to unintended consequences in low-resource environments.
Patient-Centered Outcomes Research Trust Fund
Karin Rhodes, M.D., M.S., Office of the Director, AHRQ
Dr. Karin Rhodes described the Patient-Centered Outcome Research Trust Fund (PCORTF), which allocates funds for patient-centered outcomes research and subsequent dissemination of evidence. AHRQ contributes to the latter activity by disseminating findings widely to healthcare stakeholders through tool creation and integration of information into clinical decision support. AHRQ also supports the training of researchers to advance PCOR research capacity. Following the recent reauthorization of the PCORTF, AHRQ anticipates receiving about $1 billion over the next 10 years.
The agency is conducting strategic planning to create a strategic framework, ensure stakeholder engagement, invest in infrastructure, and evaluate. The framework focuses on the following goals, which are being developed by a strategic planning committee:
- Synthesize and support the dissemination of evidence into practice and train the next generation of patient-centered outcomes researchers.
- Empower equitable whole-person care across the lifespan.
- Improve health outcomes by promoting high-value, safe, evidence-based, integrated, coordinated, team-based, patient-centered care, with a focus on underserved communities.
The agency is determining detailed priority areas and is seeking external feedback. Public input can be offered at https://www.ahrq.gov/pcor/strategic-framework until May 24, 2022. Public workshops will be convened during June and July 2022. The agency has established a Subcommittee of the NAC (SNAC), which will begin to finalize AHRQ’s strategic plan during June 2022. The SNAC’s charge is to provide input on the following:
- The PCORTF strategic framework.
- Portfolio development.
- Innovative approaches and methods for dissemination, implementation, and training.
- Outreach to stakeholders and potential partnerships.
- Strategies to ensure diversity, equity, and inclusion.
Discussion
Dr. Bitton asked the members to consider the fine points of the strategic priorities, especially those related to payment and healthcare quality.
Dr. Yu raised the idea of engaging patients, families (consumers), and other stakeholders into the discussion. Community workshops could serve to elicit consumer ideas about safety and more.
Dr. Speights also highlighted engagement, as well as equity, racism, and whole-person care across the lifespan.
Dr. Bitton asked how the strategy will intersect with AHRQ’s overall role. Dr. Rhodes responded that engagement with the many centers occurs in both cases, leading to integration of the efforts. Building infrastructure provides additional overlap.
Caroline Carney, M.D., raised the issue of approaches to interacting with insurance institutions to increase patient satisfaction with navigating the usage. Dr. Ivory suggested that the SNAC consider issues within informatics—that is, IT, artificial intelligence, and machine learning.
Dr. Rhodes asked the participants to consider how the SNAC might position itself to address the healthcare system. Dr. Lateef stated that the subcommittee might consider the impact of measurement, for example, of healthcare quality during COVID. Dr. Schmitz proposed addressing ways to better communicate within the community. Examples of good- shared governance in healthcare systems exists. Dr. Yu noted the issue of costs from adverse events.
AHRQ’s Role in Healthcare Financing Research
Joel Cohen, Ph.D., Center for Financing, Access, and Cost Trends, AHRQ
Dr. Joel Cohen presented a session on AHRQ’s work in health economics/financing research. He described three main roles: collect and disseminate data; conduct, support, and manage studies; and provide technical assistance. Major data programs are the Healthcare Cost and Utilization Project (HCUP) and the Medical Expenditure Panel Survey (MEPS). The agency recently created and made available a social determinants of health data file. Topics of supported research studies include healthcare costs and financing, access to healthcare, and quality of care. AHRQ also provides technical assistance inside and outside the federal government.
The agency has conducted groundbreaking work in areas such as insurance coverage, medical expenditures, and the use of care. AHRQ can look at population subgroups and disparities. It has a unique ability to obtain nationally representative information on healthcare expenditures by condition. It can examine use of care, disparities, and insurance status. Dr. Cohen provided an example of a study of the distribution of health expenditures, by user types, within the U.S. population throughout many decades. The study found that a small proportion of the population accounts for a large percentage of healthcare expenditures. That trend has continued.
Dr. Cohen noted AHRQ’s work to examine eligibility for public programs, such as Children's Health Insurance Program (CHIP), which revealed the importance of a person’s family, structure, income, and other characteristics. This work helped support the reauthorization of the CHIP program. A more recent AHRQ paper on the coding intensity in Medicare Advantage plans involved risk adjustment and showed an avenue to overpayment.
Dr. Cohen stated that his center will present many topics at the meeting of the American Society of Health Economists in June 2022.
Discussion
Dr. Valdez stated that many economists use methods, along with clinical trials, that feature difference approaches. Healthcare managers rely on resource analysis to make allocations. Resource sustainability issues act within social issues. There will be future pandemic waves and technological innovations. All these forces are at play as we try to deal with out-of-pocket spending. AHRQ itself needs to allocate resources—aided by the NAC. Should AHRQ focus on a robust intramural program or develop a more robust extramural program? What might a balance be? What topics should the NAC focus on, for example, new techniques, new technologies, new young employees? Dr. Valdez encouraged more strategic thinking.
Dr. Jacobson noted that the MEPS program misses data on people in institutional care settings. Data on infused drugs are also not captured in a rigorous way. Dr. Yu wondered whether the HCUP data could be made more available and accessible through better public interfaces and navigation. Dr. Cohen responded that the MEPS program has been working to make the data more accessible, for example, using visualizations. Dr. Yu suggested working with consumers to help address cost issues.
Dr. Pham referred to a national gap, asking the data programs to consider measuring the contribution of private equity to healthcare delivery and outcomes. With better information and understanding, funding could be steered toward better paths. Dr. Buntin encouraged AHRQ to partner more with the Centers for Medicare & Medicaid Services (CMS) in data activities.
AHRQ should ensure that MEPS and HCUP are accessible online at data.gov.
Dr. Carney noted that much private equity is given to the behavioral health space. She cited a need to diagnose better/earlier mental health conditions in primary care with a goal of reducing downstream costs and morbidity. An economic study and a study of the relationship between telehealth and quality of care would be welcome. The field would also benefit from study of alternative treatments and their influence on costs. Dr. Bitton noted that AHRQ can serve in the role of convener, supporting conferences for policymakers on such issues.
Dr. Schmitz proposed that AHRQ support studies of the relationship between the use of care and access to care. For example, analysis of data on patient transfers and diagnosis codes could reveal better ways to keep patients close to home and with reduced costs.
Patrick Romano, M.D., noted that many COVID-era exceptions are being phased out, which might impact access to care. AHRQ could seek to determine lessons learned from the COVID era with respect to policy changes that occurred. How will the United States address issues such as Medicaid eligibility? AHRQ can help to determine the role of telehealth to improve access and quality of care. Its data can inform responses to current changes in the healthcare system (e.g., mergers).
Dr. Ivory stressed the importance of the financial aspects of the healthcare team. She noted that the Department of Labor recognized a worker shortage before the pandemic. AHRQ could study the effects of this shortage.
Dr. Lateef raised the issue of overfunding related to coding. AHRQ could present data that could be used to move toward a proper use of coding, respecting the many subpopulations. It could translate data into better policy. Dr. Cohen confirmed the importance of this issue and highlighted the need to look at distributions, different aspects of health plans, and what the use of averages can miss.
Dr. Yu asked whether AHRQ plans to define the total cost for the COVID pandemic. Dr. Cohen replied that AHRQ coordinates with other agencies and has used HCUP data to understand capacity of the system during the pandemic.
Dr. Pham raised the topic of modernizing risk adjustment. Traditional tools that are regression- based are not sufficient. Newer tools recognize many socioeconomic factors and can predict service use and outcomes. AHRQ could lead the identification of contributing factors. Artificial intelligence must be deployed in this effort. Dr. Carney agreed and supported algorithms and new machine learning models. Dr. Jacobson stressed the importance of data collection. Dr.
Lateef added that AHRQ’s lack of bias can offer clean interpretation of data and therefore drive the downstream impact of programs on, for example, equity.
Public Comment
There were no public comments.
Final NAC Input and Chair's Wrap-Up
Dr. Buntin stated that extramural support has been a good way to extend AHRQ’s reach. The Jacobson-Kronick work serves as a good model for pairing intramural and extramural researchers. Dr. Pham asked whether AHRQ investment in an extramural program might interact with or replicate NIH study sections. Dr. Valdez responded that NIH is a biomedical institution and does not invest in economic questions as a rule. Recently, NIH has weighed in regarding costs and financing as one of its minor roles. AHRQ, on the other hand, has substantial research authority in such areas (as in payment arrangements).
Dr. Romano expressed enthusiasm for strong extramural research by AHRQ. The health economics area often needs better funding. AHRQ could support research in pricing, competition, private equity, and measures. Dr. Valdez stressed that AHRQ is the home for health services research, which features interdisciplinary work.
Dr. Yu added that AHRQ can help integrate health services, addressing topics such as training, team/staff care, and whole care.
Dr. Bitton presented reflections on the meeting:
- The goals and role of AHRQ are unique in the federal ecosystem, where there is mainly a disease-and-science focus. AHRQ can pursue follow through, determining how to improve systems. It should focus on translational research, seeking new strategies and voices.
- Regarding boundaries, AHRQ can strive to consider the widest conceptions of health, identify and address gaps, and extend outside the healthcare system.
- AHRQ can include a focus on good counting and good measurement. It has a role in determining who should be counted, addressing fundamental problems, and how the dollars flow in the healthcare system. Counting can extend to ensuring that all necessary workforce members are present.
Dr. Speights added the importance of studying the well-being of the physicians and others in the healthcare workforce.
Dr. Edgman-Levitan added the importance of studying and advancing the culture of the healthcare organization as a good place to work.
Adjournment
Drs. Valdez and Bitton thanked the NAC members, presenters, and AHRQ staff. Dr. Valdez welcomed additional comments, which can be forwarded to the office. Comments could include ideas for future meeting topics and ways to improve the meetings. Dr. Bitton stated that the next NAC meeting will occur on Thursday, July 21, 2022. He adjourned the meeting at 2:45 p.m.
Respectfully submitted,
Edmondo J. Robinson, M.D., M.B.A., M.S., Chair
National Advisory Council
Agency for Healthcare Research and Quality
