4. Overlap and Coordination of Federal Agency Research Portfolios in HSR and PCR
The previous chapter described the breadth, scope, and focus of the HSR and PCR portfolios of different federal agencies. That discussion indicated that agencies have distinct focus areas and also fund research covering similar topics, particularly when looking at broad domains such as Quality of Care and the Organization of Care. To understand the nature of any overlap in portfolios, this chapter examines instances in which federal agencies fund research in similar topical areas to understand the nature of any overlap in portfolios. In particular, we sought to determine whether and in what circumstances that overlap is complementary (e.g., covering different aspects of a topic or covering a common topic in regard to a different population) or redundant (i.e., essentially duplicating the focus of another agency’s study). We also sought to identify mechanisms agencies use to coordinate their research efforts.
In the chapter, we first differentiate various types of overlap in HSR and PCR funded by agencies and describe formal and informal mechanisms of coordination. We then note research areas considered by individual study participants to lack sufficient coordination and discuss challenges to interagency coordination of federally funded HSR and PCR projects.
Types of Overlap
TEP and interview participants across several stakeholder groups noted that overlap in research funding—that is, when different agencies fund research in the same topic area—can be complementary and advantageous, rather than redundant. Complementary research includes instances when agencies fund projects addressing different facets of a research topic, as well as when agencies devote or combine resources for similar projects on an underfunded topic in an additive fashion. At the same time, stakeholders acknowledged that redundancies in research efforts do occur across agencies. When such redundancies are recognized, study participants from within and outside the federal government observed that agencies generally work to avoid duplication and ensure funding of research that reflects the mission and expertise of each agency. Indeed, some examples of complementary agency research were motivated by the identification of redundant overlap by federal leadership, policymakers and stakeholders, or the agencies themselves.
Overlap in Research Portfolios Was Mostly Complementary
Agencies Funding Research on Distinct Aspects of a Topic
While study participants acknowledged overlap in research portfolios that might create duplication, this overlap, if coordinated properly, was observed to be important in allowing agencies to fund the complementary research approaches needed to make headway on particular problems in health care delivery. As described by a leader of a consumer group, these “fuzzy boundaries” can create “sweet spots” for agency research efforts to complement each other:
Yeah, there’s been fuzzy boundaries that might create duplication. But I kind of think of it as like a nice Venn diagram, where there is overlap and it creates that sweet spot, where everybody is doing what they’re supposed to be doing, based on their mandate as an agency. When there is a sweet spot, that’s where action and change can really take place. I think there should be some overlap, quite frankly.
A researcher in health care disparities similarly described the overlap in research areas between AHRQ and NIH as complementary and generally useful:
AHRQ . . . covers any disease state. NIH is organized around disease states or populations. So there’s going to be overlap, but I think there’s a lot of areas where they don’t overlap. And I don’t think the AHRQ-NIH overlap is problematic—I think it’s . . . actually good. . . . [T]here are issues that are not organized around a specific disease, which is the way NIH is organized, and AHRQ is better suited for that.
For example, a federal research leader at CMS described how research evidence generated by other agencies such as AHRQ and NIH informs the types of payment and delivery models that are tested by CMMI.
Are there areas of overlap? Certainly. But I see the contribution that each of us [agencies] makes as different, but complementary. Like we can’t implement a model in CMMI out of thin air, right? It should be based on the evidence that AHRQ produces out of the research that they do about how the systems are currently functioning. And the way that we measure quality, for example, or the kind of expectations we impose upon our model participants should be informed by the work NIH does around what should care around a chronic condition look like clinically, right? So we each play a critical distinct, but complementary role.
The same federal research leader reported work on a diabetes prevention model that involved collaboration with CDC “working hand-in-glove” utilizing not only CDC research expertise in diabetes prevention, but also CDC’s prevention certification for providers and data collection. Likewise, a federal research leader from AHRQ recounted how similar overlap on the topic of PCMH reflected collaboration with AHRQ providing foundational evidence on PCMH used to develop the CMMI’s Comprehensive Primary Care demonstration model, as well as modeling to inform the design of the evaluation.
In primary care, when CMS decided, CMMI specifically, to develop new models of payment for primary care, they came and met with AHRQ. And we taught them about the PCMH and what we were seeing in the evidence were important factors. And they developed CPC [Comprehensive Primary Care] partially based on consultations with us. . . . They were going to evaluate that program, and we ran the data and did some modeling and . . . worked with them to develop changes to the program and their evaluation that made it possible that they’d be able to see an effect. And they listened to that. And I think this very large program was much better because of the partnership. It was AHRQ’s investments in primary care research methodologies that allowed us to guide them on that.
Overlap with the VHA on the PCMH topic also reflected complementary use of AHRQ evidence on primary care transformation to inform the VHA’s implementation and evaluation of its patient-aligned care team (PACT) medical home model. The federal research leader from AHRQ continued:
Another place we’ve also had some collaborative successes is with the VA. The VA as a complete system recognized the importance of primary care way before a lot of other folks and really wanted to develop that. We partnered with them on their development of the PACT model, which is their PCMH. And they used some of our work . . . I’d love to continue to see more.
The consumer group leader above provided an example of complementary research overlap that included distinct research roles among agencies, as well as facilitated coordination with other research roles (e.g., CMS payment policy) and private sector stakeholders, such as the Joint Commission.
[W]e recognized that everybody had a role to play where CMS, you need to make sure that CMS would pay for a universal bilirubin test, that the Joint Commission would issue a sentinel event alert, alerting hospitals to test all babies; that CDC would fund some research on the impact of implementing a universal bilirubin screening in a large health care system and where AHRQ did studies at other hospitals who did that, as well. . . . It was really gratifying to see them all get around what we needed to accomplish, and they all did their piece without competing or doing the same kind of research.
A federal research stakeholder at ASPE described how their office is an active consumer of other agencies’ research both to avoid duplication and fulfill its unique role in translating research for the policymaking process.
We [ASPE] definitely are consumers of AHRQ and NIH research, so in terms of trying not to duplicate, but it is our job to know what’s going on at those agencies so that we can take advantage of all that they’re doing so that it can feed into policymaking. So that’s not directly an AHRQ role, but it’s directly, I think, an ASPE role. We don’t try to duplicate it, but we have to know and value and compile it, synthesize it, maybe summarize it so that it can be further consumed into the policymaking process.
Agencies Funding Additional Needed Research on a Topic
Other stakeholders noted cases in which agencies sponsor similar projects on important but underfunded topics. This type of additive overlap allows focusing of resources across agencies to address pressing or neglected issues in health care delivery and improvement. One such area commented on by several stakeholders was PCR, such as the case of a PCR researcher who noted “some overlap” between NIH and AHRQ in PCR funding but added that “the funding is inadequate in the first place, so I would hate to see any overlap eliminated.” A state-level policymaker agreed:
My impression is that the funding for primary care research . . . is so small that overlap is not an issue. There’s not a lot to go around, so I don’t think overlap is what we’ve got to worry about. Maybe the overall size of the funding and what the priorities should be are relevant conversations, but less so overlap.
A federal research stakeholder from AHRQ similarly described the general lack of direct overlap in PCR projects due to the “dearth of funding.” This stakeholder noted that the overlap that does exist in federally funded PCR tends to consist of “the kind of projects you should test more than once before you put all your money down on it; so it’s the important checking of projects” for confidence in results.
A delivery system leader pointed to health care workforce research as an area that exhibits both additive and distinct complementary overlap among agencies:
It’s hard to say there’s overlap when there’s such dramatic underfunding of services transformation. One area that’s of particular [note] to me is the different roles that HRSA and AHRQ have in workforce research; that AHRQ seems more interested in teams and in advanced models of workforce planning. HRSA tends to be more focused on the individual disciplines, in my observation, and also in sort of traditional ratio-based planning for workforce, sort of different perspectives. I wouldn’t say that I see much in the way of overlap just because it’s such an underfunded area.
Overlap Among Research Portfolios Was Viewed as Less Problematic Than Coordination
Difficulty Identifying Current Redundancies
In general, TEP and interview participants had difficulty identifying current problematic examples of redundant overlap. As a state public health leader remarked:
Nothing that I think would be problematic or notable, you know . . . what comes to mind, for example, is CDC may be supporting a program . . . then GAO [Government Accountability Office] may come along and, at Congress’ request, do an evaluation, . . . and the program would have reports . . . intended to impact our work at a state and a county level. So it wouldn’t be, you know, duplicative, but certainly [reports] on a similar program or topic. But other than that, nothing really comes to mind as a duplication of sorts.
Like other health system delivery leaders, this one did not see obvious instances of overlap among HSR and PCR funded by federal agencies, partly due to the difficulty of tracing the origins of the many studies they are trying to use. However, given the challenge faced by industry professionals in identifying overlap, the leader encouraged funders to strive for as “integrated and coordinated” a research agenda as possible:
I think there is some overlap, but I don’t come away saying, “Gee, I’ve already seen this, or didn’t I see this in a different—“ I mean, because there’s so much also private research at quasi-public institutions like the Kaiser Family Foundation or Commonwealth Fund or Peterson Foundation. So, I’m trying to read all of these things and it’s blurry. I think from the federally funded standpoint, I think some sort of way to organize and eliminate the overlap where it does occur, so that it was a single research agenda—that may be impossible to accomplish, but I think that would certainly be advantageous for those of us who are in the industry, trying to keep our heads down every day, to keep executing. I think the more that we can be integrated and coordinated on the research agenda, the better. But I don’t have a specific area where I would say these two things are overlapping and one of them needs to go away.
Concern About Coordination More Than Redundancy in Research Portfolios
Other stakeholders were explicit in stating that redundancy in overlap among agencies was not as much a concern as the coordination of research funded by agencies. As an insurance industry leader stated, “I don’t think overlap is the issue. I think disconnect is the issue.” A leader of a state-level payer organization likewise remarked:
I worry less about redundancy than I do about inconsistency. Is SAMHSA and AHRQ, who are both looking at issues on opioids and its relation to primary care, doing a whole different set of measuring what that means? And [is that] out of sync with what patient-centered medical homes are doing, which are also looking at the engagement of primary care docs in substance abuse issues?
Agencies Were Generally Sensitive to Redundancy in Research Portfolios
This emphasis on coordination more than overlap may be related to observations that federal agencies are generally sensitive to redundancies in research portfolios and inclined to avoid and resolve instances once recognized. A federal research leader from NIH commented that, among other agencies such as AHRQ, CDC, and FDA with which the agency interacts, “everybody sees the merit in facilitating transfer of research from one agency to the other” and “the value of coordinated research.”
A federal research leader from CDC noted that challenges with managing the interface among agency research portfolios frequently involve “miscommunication and expectations of the classic lanes for different organizations . . . and when people cross lanes, that causes consternation amongst everybody.” Part of the inclination to stay within “lanes” is a desire of agencies to focus on research that produces value-added based on the distinct strengths of an agency’s portfolio, as described by a federal research leader from the VHA:
Obviously, we have a lot of veterans with diabetes, but we’re still going to be a drop in the bucket of all the health services research that comes out of NIDDK, or NHLBI. So we are focusing a little more on things that have elements that are more specific to care in the VA, like multi-morbid chronic disease, or patients with co-occurring mental health disorders, or the role of telehealth and things like that. But, you know, just a single kind of vanilla intervention for patients who just have diabetes is not really a great space for us.
There is also general recognition of the consequences from federal leadership and policymakers for appearing to be performing duplicative research or operating outside of their “lanes.” A PCR researcher provided an example of AHRQ and PCORI, a nongovernment institute, which both receive funding through the PCOR Trust Fund established by the Affordable Care Act:
I don’t think there’s much overlap. I think AHRQ and PCORI is certainly where there was the highest risk of overlap and I think, for the most part, they sorted it out. . . . [T]he primary care discipline, researchers within family medicine and people working on policy, have worked very hard to help them prevent overlap because we know that overlap could politically hurt both.
Examples of Agencies Resolving Redundancy in Research Portfolios
Indeed, stakeholders described examples of complementary agency research that were motivated when leadership, policymakers, and other stakeholders identified and pressed agencies on problematic overlap in research efforts. For example, several federal research stakeholders described active complementary research efforts among several agencies around HAIs. An AHRQ federal stakeholder discussed how the agency is in contact with CDC, NIH, and other agencies through “various committees, the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria—PACCARB, an HHS workgroup, and the National Action Plan to Prevent Healthcare-Associated Infections,” with “CDC’s focus more from the public health angle, [and] AHRQ looking at the health care delivery system [with] a focus on implementation and spread” of HAI prevention interventions. A CMS federal stakeholder likewise discussed that agency’s involvement in the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria and use of CDC’s National Health and Safety Network surveillance system for data on HAIs in hospitals and other health care facilities. A leader of a consumer group agreed:
Yeah [the HAI National Action Plan] was a step forward in collaboration, [even though] the action plan’s goals were not met in the first round. . . . [I]n general, agencies work in silos. I’ve seen in my arena of patient safety a bit more collaboration among agencies than there was in the past, and that’s a good thing.
However, the impetus for the HAI National Action Plan was a congressionally requested GAO report and subsequent hearings, which were partially motivated by consumer and other stakeholder agitation for progress on a rising HAI epidemic, and which criticized HHS for redundant research across multiple agencies. Of particular concern were redundant priorities related to prevention practices and data systems for measuring and reporting HAI trends (Mendel et al., 2014). As recalled by a state-level health care industry leader:
At one point, especially in the HAI space, it was pretty redundant. But . . . [the chair of Steering Committee for the National Action Plan to Prevent Healthcare-Associated Infections] had, through HHS, tried to bring together the partners, and I participated in some of those calls where they had CDC, they had AHRQ and CMS at the table to try to do some sense making internally. We’ve gotten better at that. I think at first everybody was just trying to, you know, rush there first.
In other instances, federal stakeholders identify and address emerging overlap in research portfolios on their own, such as with the example provided in Chapter 5 regarding the formation of a federal work group on PCMH research.
A leader of a consumer group offered another example illustrating how, once they are “around a table,” federal agencies work to leverage areas of overlap in research portfolios with both other federal and nonfederal stakeholders:
As a consumer, when I first met CDC, HRSA, the ASPE Office, AHRQ, NQF, we all came together around a table and it was amazing, as a consumer, that they didn’t know each other. We thought that they worked together on solving problems, but we basically brought them together and then they identified the overlaps and they really leveraged those overlaps. But there was no real duplication, because everybody was doing it from their own angle.
Mechanisms of Coordination
As mentioned above, study participants often discussed overlap and coordination of research portfolios together. Here we describe formal and informal mechanisms that stakeholders reported using to coordinate federally funded HSR and PCR among agencies, as well as the dynamics of that coordination, areas perceived to have insufficient coordination, and challenges in coordinating HSR and PCR among federal agencies.
Formal Mechanisms of Interagency Coordination in HSR and PCR
TEP and interview participants described several formal mechanisms of coordination of HSR and PCR among agencies:
- Interagency steering committees and task forces.
- Agency advisory committees and other processes for regular information sharing among agencies.
- Project-specific advisory committees, roles, and coordination.
- Federal departmental clearance process.
Interagency Steering Committees and Task Forces
Interagency steering committees or task forces are often the result of high-visibility policy issues of urgent concern. The steering committee for the HAI National Action Plan was spurred by growing concern among consumers, public media, and congressional leaders about the emerging HAI epidemic in the 1990s and early 2000s, as referenced above. A federal stakeholder described the current opioid crisis as spurring similar interagency coordination and research planning:
So the opioid epidemic is really a major problem. The department identified it as a major priority, one of the Secretary’s four priorities. There’s been a lot of discussion across the department, across the agencies who is best situated to do study A. There’s been research planning, if you will. Then there’s communication among the agencies to drive it, develop coordination around the research enterprise, the data enterprise. . . . It’s almost the forcing event in a way, in a positive way . . . such that we’re coordinating in ways that maybe we would not have done before because we’re accountable to the Secretary. . . . So that has helped us stay focused and collaborative.
Another federal stakeholder commented on how a congressional policy priority resulted in an interagency work group on diagnostic safety:
Congress identified diagnostic safety as a high-priority area. And they essentially told AHRQ, “Please get together an interagency work group, so you all can work together and try to solve this problem, you know, and come back with recommendations.”
In other instances, an agency might form such a workgroup after discerning that other agencies were beginning to fund research on an emerging topic, such as PCMHs:
I think AHRQ has been seen [by] people within the department, we’ve reached out and they’ve reached back to us about primary care. So when we were doing PCMH work, we had a federal work group and we had almost every federal agency in that space coming regularly and talking about what they were doing and what their biggest questions were and AHRQ letting them know what we were doing and staying out of lanes and coordinating, aligning. It worked really well.
Agency Advisory Committees and Processes for Regular Information Sharing
Participating in standing advisory committees was another mechanism for staying informed about other agencies’ research agendas and coordinating overlap. A federal stakeholder illustrated this mechanism through an example of a teleconference call for AHRQ’s Advisory Committee.
I was just on [AHRQ’s] Advisory Committee call, and they’re rolling out—identified three priority areas. I was just noticing that two of them are pretty close to things that we’re working on, and so we’re talking about collaborating. One of them was high cost or high needs patient. [Then] multiple chronic conditions. And then they are interested in improving diagnosis, and that’s an area that some of our researchers have been leaders in, so we’re thinking about trying to partner with them.
A federal stakeholder from ASPE described a process that the agency has implemented for regular consultation and information sharing with other agencies on mutual research interests and agendas:
Every year we develop a research plan. We have a formal consultation process where we go out to visit each of our agencies. We talk with them about, “Here are some ideas we have about research projects we think might be of interest to you.” They will ask us in turn about projects they would find it of interest to partner on with us, or for us to go do. We develop an annual research plan. It gets approved by our leadership, and then we put it into effect for the year.
Agencies also engaged in various project-level mechanisms to coordinate research efforts, including sitting on project-specific advisory committees and cofounding projects. A federal interview participant from AHRQ described the formation of federal steering committee for their recent EvidenceNOW project (Agency for Healthcare Research and Quality, 2019b) and its ability to manage and leverage overlap among agencies.
For EvidenceNOW, we set up a similar kind of federal steering committee, which for the first few years and especially in the development phase was very, very active, you know, allowed us to make sure that our initiative and CMS’s new payment models, that we were clear about who could participate and how we would not in any way hurt their evaluation plans. And, in fact, they gave permission and incorporated EvidenceNOW into their evaluation plans in the few places where there could’ve been overlap and encouraged people to do both their payment and our technical assistance support. NIH, specifically NHLBI, looked at our program very closely and helped us see that there was no overlap. They had one program, . . . but targeting a slightly different aspect of the issue. So really little worry about duplication and a lot of good coordination.
Researchers also cited experiences in which agencies coordinated dual funding of projects. Although members of the study’s Federal Advisory Group mentioned the relative rarity and recent restrictions put on these arrangements, a health disparities researcher mentioned utilizing dual applications for funding between AHRQ and NIH, such as a study where “AHRQ had a study section that I thought was better suited to review the proposal, but NHLBI had the bigger budget. So I got dual submission and . . . it worked out perfectly.” Another researcher described an experience in which the initial funding agency suggested a dual submission:
I think they try not to overlap too much, [and] there is some collaboration. I was talking about silos before, but sometimes when I have submitted a grant, they will say, “This should get referred to another agency.” And then we talk with the project officer ahead of time. They say, “You might want to have dual review.” So if they have overlap, and then if you have a score . . . sometimes they’ll scrape money together from both to get it done.
Departmental Clearance Process
As with many federal departments, agencies within HHS are often required to submit policy-relevant agency publications or programs for internal clearance and review by other agencies. As a federal stakeholder explained, although clearance typically happens after a research or evaluation project has been completed, it provides a “communication vehicle” for staying on top of other agencies’ research portfolios.
The [HHS] department clearance process itself is a way of coordinating what’s happening. There’s an interim communication process where agencies that are doing work send it into the department for possible review. And, oftentimes, we’re learning and keeping in touch based on reports that are being released. AHRQ, every year, releases an annual report on disparities and quality [which] they release before to the department. . . . So we’re part of that clearance process. That helps us keep up with what the agency is doing. All of our agencies are big. They’re busy, and it’s . . . impossible to keep on top of everything that they’re doing. But that clearance process is a communication vehicle, if you will.
A federal stakeholder from CMS describes using the clearance process and other mechanisms, such as project-level participation in design teams, to coordinate with other agencies on the front end of developing a new CMMI payment model for demonstration.
As we’re thinking about the design of a new model, we start doing our scanning and figuring out, “Well, we need to touch base with this person. We need to touch base with that person.” So as we’re doing the design, we start reaching out. And often we’ll have those partners or sister agencies . . . identify someone to help, sit on our design team. And for every model, we develop an Innovation Center Investment Plan . . . that goes through an official formal clearance throughout the agency and throughout the whole department. Most of the agencies that I’ve identified are all operating division within the Department of Health and Human Services, and so it gets cleared that way. And our sister agencies—not only are they working with us on the development of the model, they also get the opportunity to officially comment on the model and shape, what it looks like in that comment process.
It should be noted that such clearance processes are generally limited to agencies within a federal department such as HHS, and other mechanisms would have to be utilized to coordinate with agencies in other federal departments.
Informal Mechanisms of Interagency Coordination in HSR and PCR
Personal professional relationships of staff across agencies are often formed through work on formal interagency committees and mechanisms described above, as well as movement of staff among agencies. Federal stakeholders pointed to the importance of such personal staff connections and networks to identifying and coordinating potential areas of overlap in federally funded HSR and PCR.
Personal relationships are really important. That’s why we go out to meet with them, to help build personal relationships. We talk with agency counterparts throughout the year. You know, we have lots of opportunities to engage with our agency counterparts, and it’s important that we do that and that we know them, and they know us. The first important thing is personal relationships. If it was just a paper process, it wouldn’t work.
A different federal stakeholder illustrated how being able to “phone a friend” at another agency can be leveraged to connect to appropriate other contacts at that agency for particular projects or research efforts.
The reality with any big, complex organization like HHS, having a personal relationship with the other side helps facilitate that relationship. And I know a handful of folks at AHRQ that are sort of my go-to people to call, handful of people at HRSA and the same with SAMHSA and other places that I call when I need to phone a friend. And then they help connect me to the appropriate person, but that happens in a bilateral fashion.
Dynamics of Interagency Coordination in HSR and PCR
The dynamics involved in agency coordination of a research topic are often governed by authorization from departmental leadership or policymakers, and the agency to which funding has been appropriated. As explained by two different federal stakeholders:
Opioids is a good example where you have a specific act of Congress that authorizes or even authorizes and appropriates particular monies, and then [it’s led] depending who it’s appropriated to.
The way this happens in the federal government is when there’s an interagency committee, one agency takes the lead, but everybody has to report back on their work.
As explained by other federal stakeholders, other agencies become involved depending on the expertise or distinct value-added that particular agencies bring to the research topic.
It depends on the topic . . . [and] the type of collaboration depends on the expertise of the sister agency. CDC has a pretty broad footprint, I might argue, around specific disease topics and we worked with other operational divisions and staff divisions, accordingly. Same thing with ACF or ACL, with respect to child health, the maternal and child health issues or community-based issues.
Another way we work with [other agencies] . . . is we partner with them on things where we have value add, particularly around evaluations.
A member of the HSR TEP also described different ways agencies can coordinate their research efforts, such as by employing a divide-and-conquer strategy or more interactive collaborative approaches:
What does “coordinate” mean exactly? I can see two very distinct streams. One is you divide up the territory and “coordinate” means we’ll do this, you’ll do this, and you’ll do that. Or it can be much more truly interactive, like joint study sections, co-funding, getting people around a room like this and saying, “Not only is this the topic, but this is what we think are the right priorities for research under this topic, and so we’re all going to sort of sing from the same hymn book on that.”
Another member of the HSR TEP suggested that information sharing strategies more broadly can provide the foundation to proactively identify commonly worked research topics and eventually lead to various types of coordination.
I was thinking about the definition of “coordinating” as well, and I think there’s sometimes a third definition, it’s the sharing of information. I know that CMS, underneath some of its patient safety work, brings together a lot of the different federal agencies, CDC, IHS, AHRQ, for monthly calls in which they share projects that they’re working on and share information. I don’t know that there’s any coordination of the work. There’s more information sharing, which is helpful, but I think, you know, a step further beyond that really is what’s needed to make an impact. It could lead to coordination, ideally.
In response to these results, members of the study’s Federal Advisory Group noted that the appropriate form of coordination in a research area is frequently a balance between formal and informal mechanisms, depending on the complexity and magnitude of the research topic and numbers of agencies involved. Formal coordination mechanisms from large interagency task forces to project-specific advisory committees may be necessary depending on the range of agencies and size of the research efforts being funded. However, the time and resources, as well as unintended risks of overemphasizing agency “turf” versus collaboration, involved with formal mechanisms may not warrant their use for all topics. When not specified by leadership or policy authorization, members of the Federal Advisory Group, like other stakeholders cited above, generally considered agencies adept at developing appropriate mechanisms of coordination— including formal and/or informal—to positively leverage overlap in portfolios for a given research topic or initiative.
Lack of Systematic Processes for Identifying Potential Overlap in Portfolios
Although TEP and interview participants generally agreed that agencies were inclined and able to coordinate research when overlaps in portfolios were recognized, a number of stakeholders commented that identifying overlaps to ensure coordination appeared to be, in the words of a leader of an accreditation organization, “sporadic attempts.” Even the leader of the consumer organization who provided examples of effective interagency leveraging of overlaps described those efforts as “kind of accidental coordination” that occurred through instigation of consumer groups. A state-level payer stakeholder and member of the PCR TEP, respectively, offered similar perceptions:
I think [coordination] is happening by happenstance—having been there—rather than by, “Oh, we’ll own this, you own that.”
In my world, I know of many instances of interactions and collaborations. For example, NIA and PCORI co-manage the big initiative on falls and NIA has done a number of planned collaborative conferences with FDA and with CMS, but it’s all anecdotal.
As a consequence, a member of the HSR TEP encouraged
really thinking about, you know, what are the different strengths . . . as we look at that long list of federal agencies, what strengths do they bring to the table, and I don’t think we need to be duplicative. I think that we can actually be complementary.
A consumer stakeholder also advocated for a common interagency approach for multiagency, multistakeholder research and improvement efforts to address the “big problems” of “a health care system that’s uncoordinated” itself:
I think as a nation, as we try to solve problems, one of the big problems in my opinion is that we have a health care system that’s uncoordinated, a health care system that doesn’t always address issues that matter to the patient population and that—my recommendation is that HHS, that they have an interagency approach to solving problems. But it has to be fluid and it has to operate with a sense of urgency. It needs to engage the patient community in that interagency. I think you know, when it’s around a certain problem to solve—let’s say it’s sepsis or let’s say it’s the opioids or let’s say it’s newborn safety, I think it needs to be a multiagency, multi-stakeholder approach, where everything is coordinated. And that’s just because like I could see it happen with good results. And we need from Congress way more money invested in this kind of research.
Instances of Insufficient Coordination
While TEP and interview participants stated that federal agencies were able to regularly resolve coordination issues on topics with identified overlap, they acknowledged instances in which insufficient coordination appears to have persisted. Several members of the HSR TEP identified the development of quality measures as a domain that, despite numerous past and current interagency and public-private sectors efforts, has remained difficult to coordinate. Other instances were noted only by single participants as areas they felt lacked sufficient coordination, such as broadly across the agencies addressing mental health and research on the specific issue of providers communicating critical test results to patients, although these were not mentioned by other participants.
Challenges to Coordination
Breadth and Volume of Research Activity
Among the many possible challenges to coordination within large organizations, TEP and interview participants highlighted three in relation to federally funded HSR and PCR. The first, as noted by a federal stakeholder, is the breadth and volume of research activity of agencies within HHS, let alone other departments:
What are the challenges in coordination? One of the obvious one is it’s a big department, and so there’s lots of activity happening every day. And some things that may be very meaningful on one particular day for an agency may be relevant, you know, three weeks down the road to us. And so there’s lots of productivity in the department. And being able to track all that is always a challenge in a big organization.
Differing Time Frames of Research Across Agencies
The second challenge noted by a another federal stakeholder concerns differing time frames of research among agencies, including the time lag between the identification of research needs and the production of results:
And one of the challenges is more rapid cycle research. The older HSR paradigm of brilliant researchers discover problems, study and learn about it for a year, write a grant application a year and a half later, get money to study it five years later, finish their study, take a year to write it up, and it gets published. That’s seven or eight years. That’s not what HRSA and SAMHSA and IHS need. We’ve got to be able to shorten that cycle . . . PBRNs or AHRQ’s ACTION Network are great potential examples of how that could be done. But learning systems where we can say here’s the problem, find a solution, set a bunch of people on it and a year later being able to say here’s some preliminary things that look like they’re working, and two years later being able to say now we know this. . . . Two years may be too long still for some policymakers, but it’s a heck of a lot better than the eight-year cycle we’re in right now.
Lack of Targeted Funding for Coordinating PCR
The third challenge concerns the lack of targeted funding for agency coordination of PCR. For example, a member of the HSR TEP stated that, although AHRQ is the designated lead agency for PCR, it does not receive resources for that mission (also Chapter 3), which inhibits its ability to coordinate the domain with other agencies that fund PCR:
NIH doesn’t have a primary care center. CDC is interested in primary care to the extent that it’s about prevention and public health, but that’s not the whole primary care. HRSA has the workforce part of primary care, but that’s just the workforce. That’s not the services that are delivered. The VA probably comes closest, because it actually is a deliverer of primary care and funds research on effective primary care delivery, but that’s just the VA and just veterans. I guess, AHRQ is the lead agency . . . named the lead agency, but there are no resources attached to it to carry out that mission. And I don’t think that AHRQ [can] convene all of the other agencies to talk about their primary care interests.
Study participants across various stakeholder groups emphasized the value of complementary overlap in research portfolios across agencies, if properly coordinated. Several interview participants pointed to coordination of research portfolios as a more problematic issue than redundancy. Participants observed that agencies acted to address redundancy in research portfolios and worked to ensure that funding of research reflected the distinct roles and value-added of each agency after such redundancies have been recognized. Participants also observed federal agencies to be adept at utilizing appropriate and effective mechanisms for coordination, including formal and informal mechanisms, once overlaps in portfolios have been recognized. Informal coordination mechanisms include personal staff connections and networks and were considered critical facilitators of formal coordination.
However, study participants commented on the lack of systematic processes for proactively identifying potential overlap in HSR and PCR portfolios across agencies. The process of discovering overlaps was said to be “sporadic,” “accidental,” or “anecdotal,” and to occur “by happenstance.” Individual study participants also noted research areas they considered to lack sufficient coordination. Challenges to coordination of HSR and PCR portfolios mentioned by study participants included the breadth and volume of research activity across the federal HSR and PCR enterprise, differing time frames of research among agencies, and the lack of targeted funding for a lead agency to coordinate PCR in particular.