The Trump administration could undermine its own push toward a health-care system that pays for value, not treatment, as it seeks to diminish the role of an agency that evaluates patient care.

Previous budget proposals released under President Donald Trump’s White House sought to drop the rank of the Agency for Healthcare Research and Quality (AHRQ) that funds research on improving the health system. Those proposals haven’t come to fruition as Congress continued to fund the research agency despite the White House’s requests.

It’s not clear whether those same requests will be in the FY 2020 budget plan, which is slated to be released the week of March 11.

Health and Human Services Secretary Alex Azar says one of his top priorities is transforming the health-care system from a fee-for-service model to a value-based approach that pays for outcomes. “We will take major steps in transforming our health system to pay for value,” Azar said announcing 2019 plans during his recent State of the HHS speech.

A value-based care system rewards doctors and hospitals with extra money for high-quality care, breaking away from the traditional model of paying providers for each service regardless of outcome. The AHRQ generates data about the value of health-care models by evaluating the safety and quality of specific programs.

Transforming the health-care system to a value-based payment for doctors means “we’re going to have to better understand which changes that are happening in health care are actually contributing to high value and which ones aren’t,” Lisa Simpson, president and chief executive officer of Academy Health, told Bloomberg Law. “That’s the kind of research that AHRQ sponsors.”

Trump’s fiscal year 2018 and 2019 budget requests both sought to fold the AHRQ into the National Institutes of Health, placing it below the NIH and the Centers for Medicare & Medicaid Services.

The fiscal 2018 budget proposal said the change would “preserve key activities that were previously funded in AHRQ to improve the quality and safety of American health care, while reducing or eliminating lower priority programs that may potentially overlap with activities administered by other components of HHS.”

Leaving a Void

Health analysts fear that cutting the AHRQ’s research would create a void in the hard data that are critical for value-based care.

“We have a very poor understanding of what is the secret sauce that gets organizations to high performance,” said Cheryl Damberg, senior researcher at the RAND Corp., whose expertise includes pay-for-performance and value-based purchasing. Damberg receives AHRQ funding to run one of the agency’s centers for excellence.

“It would be a substantial loss to improving American health care if their funding were to disappear,” she said.

The AHRQ has already helped reduce costs, according to its annual report. The AHRQ’s work led to a drop in hospital-acquired conditions, which are infections, falls, ulcers, and other harmful conditions a patient develops while seeking treatment in the hospital for something else.

“It wasn’t surprising at all that they would highlight hospital-acquired infections since that’s such an example of being able to actually, concretely reduce costs and save lives,” Eleanor Dehoney, Research!America’s vice president of policy and advocacy, told Bloomberg Law.

The AHRQ offers checklists on preventing medical errors that stemmed from investigator-initiated research on best practices. “It is a little ironic, since in their last budget request, they zeroed out investigator-initiated research altogether and that’s the way that the checklist came into play,” Dehoney said.

Dehoney was referring to the administration’s FY 2019 budget proposal, which would have cut health services research by $38 million, effectively cutting any new research. Congress ignored that request. Its FY 2019 spending bill provided AHRQ with $338 million, a $4 million increase from the FY 2018 enacted level.

“Congress has both times really made clear that they don’t agree with those proposals and has strengthened AHRQ’s role,” said Simpson, whose organization, Academy Health, represents health services researchers.

Unique Role

The AHRQ plays a unique role among the various health research agencies within the government. It looks inside health-care organizations to understand the impact of changes in care delivery, Damberg said. NIH-funded researchers, by contrast, only test clinical interventions.

Likewise, the CMS’s innovation center tests new value-based payment models, but that agency largely focuses on operations to run the Medicare program. Many of CMS Medicare payment decisions are informed by research that AHRQ grants likely funded five or 10 years ago, Damberg added.

Plans to stymie health services research are not unique to this Congress or this administration. House Republicans voted to eliminate the agency during the FY 2016 spending negotiations, but the final spending agreement kept the agency intact with about $334 million in discretionary spending.

Some of that dismissal has to do with the lack of awareness about what the AHRQ does. “It’s hard to make it sexy,” Dehoney said.

An HHS spokesperson referred to the agency’s annual report when asked about the role of the AHRQ in value-based care. That report touted the AHRQ’s accomplishments, including a new online statistical resource that “provides county-level comparisons of hospitalization rates for substance use, including opioids, alcohol, stimulants, and other drugs.”