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5
The Effectiveness Initiative:
Retrospective and Prospects
William L. Roper
I have a great affection for the Effectiveness Initiative, now an initiative
not just of the Health Care Financing Administration (HCFA) or even just
of the Department of Health and Human Services (DHHS) but of the entire
government. It is a far-reaching endeavor that I think will bear fruit long
into the future, and I am delighted to have had some small part in beginning it.
One of the things that I am most proud of concerning my tenure at HCFA
is the attention that the agency gave and is continuing to give to the whole
area of quality and quality measurement, and effectiveness and outcomes
research. I think this work has boosted the image of the agency not only
before the outside world, but also in our own eyes.
HCFA is no longer seen as an agency that does bad things to people. It
is one that is in the process of producing very worthwhile information and
good things for the American people.
THE GOVERNMENT'S ROLE IN EFFECTIVENESS RESEARCH
Let me comment on what it seems to me the government is doing in this
Effectiveness Initiative. First, government has the unique capacity to call
the nation's attention to an area of interest, to set something high on the
nation's list of priorities. In the business of health care and health services
research, I think that is what the government has done over the last couple
of years. A matter that was formerly of passionate interest to only a few
pioneering health services researchers is now an item of national importance.
The government is also in the business of setting priorities as to how this
research is going to be done. That is what Michael Fitzmaurice, at the
National Center for Health Services Research, and HCFA are doing in part-
nership with the IOM and other organizations around the country. We are
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EFFECTIVENESS AND OUTCOMES IN HEALTH CARE
saying that these are the areas of greatest interest; this is where research
should be done first. Yes, we would like the best information that could be
developed on how to practice medicine, what works in medical practice
across the board now, but we cannot do that, and so we have got to set
priorities. That is what this whole exercise with the IOM is about.
A second thing that the government is doing is committing unique resources
to this research enterprise. My former colleagues at HCFA are the custodians
of immense amounts of data, information that is of very great value to
health services researchers. Henry Krakauer and others are shaping that
information in ways that will be of real utility.
Of course, we aspire to create data sets that will be even more useful in
the effectiveness research that will be done in the future. The government
has resources that go well beyond those of anyone in the private sector.
What has now happened is the government has said we are going to make
this information widely available and spur research in that fashion.
The third thing that the government is doing is funding research in medical
practice and clinical effectiveness. The Congress is working its way through
appropriations for DHHS for next year. Thus far it has not seen fit to fund
fully what the President asked for in his budget for effectiveness research.
We hope that Congress will become convinced of the need to go yet higher
in this area. We need to have a loyal cadre of people across the country
pushing for the notion of health services research.
I have for the last several years been convinced by my own rhetoric of
the essential virtue of this endeavor. But I think it is going to take some
arm-twisting as well. Anyone who has an interest in this had better get to work.
A fourth thing that the government is doing is developing partnerships
with a wide array of organizations and individuals to carry out effectiveness
research. There are partnerships with foundations that have an interest in
funding research themselves; with other payers, such as insurance companies,
corporations, and Blue Cross plans; with organizations such as IOM and
others; but especially with practicing doctors.
It is absolutely essential that doctors across the country take hold of this
idea and push it forward. It cannot just be an ivory tower matter, and it
surely cannot be just a gleam in a bureaucrat's eye, however dedicated and
smart that bureaucrat may be. It has got to be something that the average
doctor in America sees as useful to him or her. That is why I think the
American Medical Association's embracing this concept is such an important
element in the whole Effectiveness Initiative.
PROSPECTS
The effectiveness and outcomes research enterprise has been given a
high priority, not just by those of us who used to be in DHHS but by Louis
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POLICY AND RESEARCH ENVIRONMENTS
33
Hays, at HCFA; by James Mason, Assistant Secretary for Health; by Secre-
tary of Health and Human Services Louis Sullivan in a number of respects;
and, indeed, by President Bush. The President at Dr. Sullivan's swearing-in
in March named research into cost-effective medical practice as a priority.
I think this sets the tone for what the Bush Administration is going to be
pushing for, from the top down.
Second, I think Congress will increase support for research into medical
practice. The leadership of the Congress Willis Gradison among the House
Republicans, Henry Waxman and others of the House Democrats, Senate
Majority Leader George Mitchell, David Durenberger, a leading Republican-
are all pushing hard to further this enterprise. Individual members, even
those not on the relevant health committees or appropriations committees,
are being convinced that we must develop a much better knowledge base for
medical practice and health care financing than we now have. It is not
sufficient to say that we do not like the fact that we are spending 12 percent
of our economy on health care. We have got to say, "How can we spend
that money better?" The answer, it seems to me, is to develop a research
base for guiding medical practice in the future.
Finally, as I alluded to earlier, the future of medical effectiveness and
outcomes research does not depend on leaders in government, whether they
are in the executive branch or the legislative branch. These people are
distracted with other things and have transient tenures. The long-term future
of this depends on broad support across the country in academic research
centers, among practicing physicians, and the American public generally.
Support is growing, but it needs to grow much more widely, much more
quickly. That is why conferences like this one are so very important.
Representative terms from entire chapter:
effectiveness research
