Two years ago, a little-known but aggressive public watchdog–the Agency for Health Care Policy and Research–was nearly destroyed after it published a guideline saying that most spinal surgery for back pain was unnecessary. Surgeons who performed back surgery didn’t like the guideline and organized a campaign to have Congress gut the federal group. The agency, which attempts to measure the effectiveness of medical treatments, managed to survive, although it no longer establishes guidelines or sets health-care policy. Nonetheless, according to its new administrator, Dr. John M. Eisenberg, the agency is reinventing itself in ways that will give it an even bigger voice in improving health care in America.
Q: Has the agency’s brush with destruction changed your mission?
A: No. Our mission is to provide the tools, talent and the teams that are needed to improve health-care quality. We need to translate the research that we have about what works and what doesn’t work into action. It’s terribly frustrating when you look at the science that we know and the science that we practice and see how far apart they are.
Q: Last week the agency announced the Evidence-based Practice Program, consisting of 12 centers in the U.S. and Canada. What will these centers do?
A: We will sponsor research that helps us understand what works and what doesn’t work. The private sector then can use that information to establish guidelines to improve medical practice.
Q: Will patients also have access to this information?
A: Absolutely. It will be available on the Internet and in printed reports. Our goal is to try to help Americans understand how they can interpret and measure the quality of care they receive. One of the problems that most people face is that they know that there are health-care services that work and some that don’t. But they have trouble figuring out which is which.
Q: Critics maintain that a lot of the things doctors do in the name of medicine have never been proven to work. Is this part of the reason for the evidence-based centers?
A: It is the reason. Spending as much as we do on health care ($1 trillion a year), we need to know what we’re getting for our money. I’ve heard it said that 80 percent of what’s in most medical textbooks has not been validated by rigorous scientific study.
Q: Canada and many European countries spend a lot less on health care, yet their populations are generally as healthy as Americans. Are we being overtreated?
A: The fact that other countries spend less has challenged us to ask why we spend as much as we do. We have a wonderful array of choices and options and access to health care for those who are lucky enough to have the insurance. But it doesn’t induce the kind of careful critical thinking about what is effective and what isn’t that other countries have forced upon themselves.
Q: Are some Americans being harmed by unnecessary care?
A: There are certainly some populations that don’t get enough and other populations who probably get more than is necessary, more than is useful, and maybe in some circumstances, more than is healthy.
Q: Many people have been shocked by the wide variations in medical practice. Across the country the rates of heart surgery, hysterectomies, Caesarean sections, tonsillectomies and other procedures vary by as much as fourfold. Are these variations driving the need for the evidence-based centers?
A: That’s a large part of it. They raise questions. Are there differences in physician training and education and patient health, or just differences in economics, that underlie the differences in utilization? You can explain some of the differences but not most of them.
Q: Until recently doctors had the final word about how they wanted to practice. Are the courts (because of malpractice suits) forcing doctors to abide by a higher standard?
A: It’s been only a couple of decades that we in this country have moved from local standards of care to having a sense that the science in Chicago shouldn’t differ from the science in Los Angeles or New York. People are people. We ought to understand what works and then adjust it for the differences in different parts of the country.
Q: Since your agency no longer will establish health-care guidelines, how confident are you that other groupsboth professional and patient-orientedwill do so?
A: Last month, we announced a collaboration with the American Medical Association and the American Association of Health Plans to develop a National Guidelines Clearinghouse. It will pull together all the guidelines that already have been written, as well as those that will come along later, and make them available over the Internet for patients and doctors.
Q: That will provide unprecedented access to solid medical information. But will it be easy for patients to get to it?
A: Yes. If you have a medical problem and you want to find out what the evidence is for one treatment versus another, you can go to the Web site and see what the various guidelines are.
Q: A long-running criticism of the medical profession is that doctors have failed to police themselves. Are they going to be held more accountable?
A: The AMA is putting together a new accreditation program to help measure doctors’ quality. We’re working with them very closely to help them assess the quality of care that physicians are providing. This is a very exciting change. It’ll be an advantage to patients and help them decide which doctor to choose.
Q: Patients frequently complain that their doctors don’t listen to them. Will that change?
A: Maybe because we didn’t have the tools or maybe because we had stoppers in our ears, we haven’t been listening enough. We need to improve the degree to which providers are listening to their patients and responding to their needs.
Q: Chronic pain is a big problem, despite pain-control measures that have been available for two decades. Why is it taking so long for doctors to implement them?
A: We haven’t paid as much attention to patients’ needs as we should have, because we were measuring things we knew how to measure. We were measuring life and death, and we weren’t measuring satisfaction and quality of life, and pain.
Q: The managed-care revolution has been criticized for being more interested in the bottom line than patient care. What can your agency do to ensure the quality of health care in the face of the big changes?
A: What’s already starting to happen is that the public is asking for information about the quality and effectiveness of care provided by health Plans. The public needs to know how well health plans do, how well doctors do and how well hospitals do. If we’re going to have a market-driven health care system, we’ve got to have information that allows patients to choose.
An edited transcript
