Expert Meeting Summary and
Identification of Next Steps
To help meet the information needs of health care reform, and to inform our own work, the Agency for Healthcare Research and Quality (AHRQ) convened a small group of policymakers, researchers, and producers of health care data. The purpose of the meeting was to begin developing a strategy to optimize the availability of information and data for enactment and implementation of health care reform. This document provides a summary of the objectives and major conclusions from this meeting, as well as an update on early steps taken to date to put the strategy into effect.
Key Summary Points
Potential AHRQ Roles in Filling the Gaps
Seven AHRQ Steps To Fill the Gaps
Midway through 2009, several factors are converging to
create a growing national push for health care reform. Costs are increasing,
health insurance coverage is declining, major disparities persist, and quality
and safety issues continue. A major public policy preoccupation in the coming
months, therefore, will be identifying and weighing alternative strategies to
reform the health care system. This scenario creates a formidable opportunity—and
challenge—for research. As health care proposals are debated and specific
reforms are implemented, there will be a vital need for solid, credible,
actionable information about the impact of current policies. In addition, there
will be a need for reliable projections about how particular policy changes
might affect health care cost, coverage, expansions, and accessibility,
quality, equity, and efficiency of the delivery system. Once decisions
are made, moreover, the system will need the capacity to track the impact of enacted
policies, see if the effects accord with projections, and make any midcourse
changes to fine-tune the policy.
To meet the needs of health care reform, research will need to
be significantly more responsive to demands for findings that are timely and
actionable. The health care research enterprise typically has been rich and
innovative, but also fragmented and supply-driven, much like health care
itself. Meeting the pressing information needs of health care reform, on the
other hand, will require a clear strategy and close collaboration among the government
agencies, private data organizations, and researchers producing needed data and
information. It also will require strong coordination between the producers
and users of that information so that researchers and analysts can to the
extent possible anticipate and then meet policymakers' need for the right
information at the right time and presented in a way that makes it quickly
understandable and usable.
As the Department's lead health services research agency,
AHRQ historically has been a major producer of research and data for
policymakers; we also have a strong role as a funder and convenor of private-sector
efforts. To help meet the information needs of health care reform, and to
inform our own work, in March this year AHRQ convened a small group of
policymakers, researchers, and producers of health care data. The purpose of
the meeting was to begin developing a strategy to optimize the availability of
information and data for enactment and implementation of health care reform.
This document provides a summary of the objectives and major conclusions from
this meeting, as well as an update on early steps taken to date to put the
strategy into effect.
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The AHRQ-sponsored meeting, "Healthcare Information Needs
and Healthcare Reform," was held March 19, 2009, at the John M. Eisenberg Building in Rockville, Maryland. Attendees included representatives from Federal
agencies, health research and policy institutions, employer groups, other such
organizations, and researchers. The
goals of the meeting were to:
- Identify the major information needs for national, State, and
other public health policy leaders, for current policymaking and subsequent
- Understand the areas in which existing simulation models and
research can provide answers and those where it cannot.
- Discover areas in which additional capacity is needed.
- Identify short- and longer term strategies for exchanging
information and filling gaps and ways that AHRQ can be helpful to this effort.
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Key Summary Points
What Policymakers Need
While the specific information
needs obviously depend on the nature of the policy being considered,
policymakers indicated several major cross-cutting requirements that affect all
questions. They need information on the likely concrete effects of unique,
specific policy proposals. They need the information quickly and customized in
a way that addresses the specific characteristics of the proposals and that
take into account the specific levers available to policymakers. Assumptions
behind the estimates and the methodological approach must be clear and transparent.
In essence, they will need to know not just the policy impact but also the
political impact of any given proposal: who benefits, who loses, what it
costs, who pays, what the effects are on consumers/patients, and what the
trade-offs are among alternative proposals. The impact on the public sector
and consumer and not just the "system" is critical. In short, they need
stand-ready capacity to provide answers with all of these attributes.
Many of the policymakers present
were also veterans of past health care reform efforts. A critical point made
by these veterans was that the need for solid data is even more critical this
time, and the data needs are much broader. While in the past most of the focus
was on improving health care coverage, or the "demand" side of health care
reform, this time information on the "supply" side (quality, safety,
efficiency, effectiveness, and equity of care) is at least as important.
Current capacity to model effects on the "demand" side is well-established (as
a result of a ramp-up during the last reform effort), but unfortunately there
is limited if any capacity to model the effects on the "supply" side. Capacity
to model the effects of policy changes on the quality, safety, and cost of hospitals,
physicians, and other providers is needed, along with capacity to model (and
later track) the impact on whole episodes of care.
Policymakers also recognized a
need for better, faster, and smoother communication with producers of the
information. They need a ready way to find out what information is knowable,
who has it, and how to get it quickly and in a form they can use.
Several entities have independent
micro-simulation models, most of which are based on AHRQ's Medical Expenditure
Panel Survey (MEPS) data. Micro-simulation capacity can examine the effects of
Federal policy financing proposals on utilization, uninsured populations,
employer-based insurance coverage, and Federal budgets related to changes in
tax policies. As noted later, however, there are enhancements that could be
made within each of these models, as well as better coordination across models.
A major purpose of the meeting was to identify major
gaps. Policymakers and researchers identified gaps in three categories: the
data itself, the evidence base on what factors affect different data points,
and the availability of projections and models based on these data.
Informing and tracking health care
reform will require solid data on all aspects of the health care system, from
insurance coverage to care delivery to outcomes. The consensus of the group
was that the adequacy of the data varies considerably from one question to
another. MEPS provides information on utilization, insurance coverage, and
expenditures by patients and employers. It also provides much of the data for
multiple micro-simulation capacities both inside and outside AHRQ. The group
had several recommendations for improving these databases and simulations on
coverage and expenditures. In particular, attendees suggested, the clinical
information and longitudinal design could be improved, and MEPS lacks
sufficient sample size for enhanced drill-down capacity at more refined
geographic and other levels (e.g., rural or near old).
The group also noted a lack of
adequate provider-side data. National Center for Health Statistics provider
surveys, while useful for certain purposes, lack the sample size needed for
drill-down. The Healthcare Cost and Utilization Project (HCUP) is a rich
source of data on inpatient care and, when used with the Quality Indicators,
can provide information on quality, safety, cost, and potentially preventable
hospital admissions, with excellent drill-down capacity. The database also has
extensive data on emergency department care and ambulatory surgery. But
physician practice data are sparse, and data that cut across episodes of care
are at a very nascent stage. In addition, little modeling has been done using
provider-based data of this sort. The group identified a need to accelerate
production of provider-side data and to accelerate modeling using these data.
Another gap identified was the
need to improve information on vulnerable populations and on disparities,
particularly through the improvement of Medicaid data, including more cleaning
of the data, faster turnaround on the data, and more linkage of Medicaid with
other data. This is important because there is a strong need to ensure that
any health reforms enacted improve disparities rather than worsening them. In
addition, Medicaid directors have noted a need for better Medicaid data for
improving management of their programs. Attendees also suggested greater use
of data from the Federal Employee Health Benefit Plan (FEHBP).
While there is recognition that an
overall data effort to expand these data sets would be extremely worthwhile and
would provide a rich source of information, the long-timeframes to plan, secure
funding, collect, and analyze data are impractical for the immediate informational
needs of health care reform in 2009. The group felt that in the short term
much could be gained by making current data more available, enhancing and
linking existing data resources, and in some cases identifying strategies to
enhance the timeliness of a subset of high-priority data. Other short-term practical
strategies could include statistical matching techniques, imputations, and
linkages. But the group also agreed that this is also the moment to jump-start
more ambitious and longer term data efforts to bring in new data because the
visibility of current gaps creates a political momentum for action. Moreover,
it was felt that health reform will not be a one-time fix; therefore, the needs
for new data will continue in the future.
A final challenge noted was the
need for data to track the impact of existing or new policies. Policymakers
need a quick way to assess the impact of any changes in legislation and payment
so that they can fine-tune these policies, and managers need this information
so that they can make improvements to cost and efficiency as well as quality.
One requirement in this regard will be good cost accounting systems that do not
exist now. An investment in cost accounting could be a huge impetus to better
tracking and management of cost and efficiency.
While data are essential to inform
health reform, they are not sufficient. To be able to project the impact of
particular policies, we need a solid base of evidence on how providers react to
particular kinds of financial and nonfinancial incentives, how patients/consumers
react to incentives, and what types of competition or health care markets are
most conducive to desired provider behavior. AHRQ and others have funded some
research on these economic, financial, social, cultural, and legal-regulatory
forces in the past, but the science is still lacking. Thus, it is often unclear
how providers will react to particular policy proposals, whether they are
incentive-based reimbursement schemes or regulatory approaches. Research and
information on delivery, recent policy relevant to organizational change, and
underlying market forces are needed. Another requirement is availability of
solid qualitative research so that we can identify not only the intended and
unintended impact of a new policy, but also when, where, how, and why it is
having this impact.
Participants agreed that multiple
independent micro-simulation models exist that apply the same host data set
(e.g., MEPS) to address the same policy initiative. This richness of models
presents some enormous opportunities. On the other hand, it was noted that
these models are quite sensitive to the assumptions that underlie them, so
different simulations often give quite different answers to the same question,
even though most rely on the same underlying data. One suggestion was to have greater
transparency about the underlying assumptions. In addition, syntheses of
current research findings that provide empirical support for model assumptions
would be beneficial to modelers.
The largest and probably most
important gap in modeling, according to the group, is the lack of modeling on
the provider side, projecting how different changes in policy, regulation,
payment, and other factors would affect health care quality, safety, cost, and
effectiveness. As the group noted, this time the health reform debate is very
much about provider cost and efficiency, along with quality and safety, so we
are going to need models not just for insurance costs and coverage. In the
short term, filling this gap will require applying modeling and simulation
techniques refined elsewhere to existing data and evidence; in the longer term,
as noted above, it requires substantially enhancing both the data and the
evidence base in these areas.
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Potential AHRQ Roles in Filling the Gaps
The group identified several
potential roles for AHRQ in filling these gaps. These included:
- Summarizing the meeting and post it on the Web as a way of
informing a broader audience and extending the dialogue.
- Convening groups of users and researchers to further flesh out
individual pieces, such as collaboration among current data modeling efforts
using MEPS and developing a modeling capacity on the provider side.
- Making improvements to AHRQ data to make them more helpful for
- Identifying new data sources that could be useful.
- Identifying ways to facilitate use of existing information and
links to enrich the data.
- Finding quick ways to track the impact of policies.
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Seven AHRQ Steps To Fill the Gaps
In reviewing notes from the
meeting, AHRQ has identified the following next steps. In the meantime, we
continue to welcome ideas on all these steps, as well as others that are not
transparency on AHRQ data used for reform:
- Post this meeting summary on the AHRQ Web site.
- Develop special section of the AHRQ Web site to highlight data
and information that would be useful to address health care reform issues. This
plan is under development.
- Provide leadership in convening public-private partnerships:
- Plan followup meetings and potentially provide infrastructure to
facilitate better communication between entities that need information about
the effects of policy proposals and entities that produce this information.
creation of evidence base on behavioral and provider impact of policy decisions:
- Solicit grants in these areas.
- Synthesize existing knowledge.
MEPS for modeling efforts:
- Develop linkage of establishment-level data to supplement
- Develop linkage of medical provider-level data to supplement
- Provide summary of set of best practices for modeling efforts.
- Explore ways to release currently restricted data to the public
in support of the modeling efforts, while still adhering to confidentiality
provisions. This may include release of State identifiers or more discrete
indicators that distinguish areas as urban or rural. Explore data-sharing
arrangements to improve data access.
- Identify potential new data sources.
- Facilitate all-claims cross-site data.
- Identify ways to increase data timeliness.
- Plan better integration of electronic health records and claims
- Enhance data on race and ethnicity.
to build simulation capacity for provider behavior:
- Support expert meeting with particular focus on provider side.
- Explore intramural project to illustrate simulation capacity for
- Enhance HCUP and other provider data to make them more useful for
longer term goals:
- Work with others in the Department of Health and Human Services (HHS)
on a strategic approach to data investments that are most responsive to short,
intermediate, and long-term HHS and national needs, and explore the feasibility
of public/private collaboration.
- Integrate advances in adoption of health information technology
and electronic/personal health records as supplements/replacements to current
data collection efforts.
- Develop and implement a data strategy to support comparative
effectiveness research in concert with these efforts.
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Current as of July 2009
Filling the Information Needs for Healthcare Reform: Expert Meeting Summary and
Identification of Next Steps. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD. http://www.ahrq.gov/data/hinfosum.htm