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Chapter 5 THE NATIONAL CENTER FOR HEALTH SERVICES RESEARCH The National Center for Health Services Research (NCHSR) was created in 1968 as the federal government's only general-purpose health services research agency and the focal point of the field. In the decade since the founding of NCHSR, the growth of health services research elsewhere in the federal government has led to confusion about what the agency's roles and objectives are, and to debate about where in the federal structure the agency or its functions should be located. Opinions on these issues are divergent. Some hold that there is no need for a general-purpose health services research agency, arguing that its func- tions could be absorbed by other federal agencies. Others, taking the view that a strong and highly visible general-purpose research agency is essential, favor broadening NCHSR's functions and strengthening its position in the federal government. This chapter describes the issues surrounding NCHSR and the arguments for and against various proposals for changing its functions and pos;- tion. It begins with a brief history of the agency and an analysis of its functions and focuses. Arguments are then presented for and against a general-purpose health services research agency. Assuming there are needs for such an agency, options for its functions, location within the federal government, and structure are analyzed. Origins To understand the issues surrounding the National Center, it is helpful to examine the agency's history. Accordingly, the committee reviewed literature and documents and interviewed persons who were involved with the National Center at various points in its development. Information from these sources indicates that some of the problems currently faced by the agency are attributable to its original conception and design and to changing circumstances in its surroundings in the federal govern- ment. 75

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76 Background The National Center was created in 1968 in response to a combination of several trends of the 1960s: (1) a growing direct federal involvement in providing, financing, and planning health services; (2) a growing recognition that problems in the health care industry were due to fundamental organizational deficiences; (3) a belief that reforms could be achieved and should be based on knowledge derived from systematic, large-scale research and development programs; and (4) the emergence of an identifiable field of health services research. Before the 1960s, the federal government's activities in health care were relatively limited and followed traditional patterns of directly providing services for particular groups (e.g., military personnel, veterans, American Indians, merchant marines) and assisting states through grants-in-aid for services rendered to others (e.g., mothers and infants, public welfare recipients). Subsidies for the construction and renovation of health care facilities were provided through the Hill- Burton program. In the late 1950s, the federal government's share of all spending for health care was slightly less than that of the states, which together accounted for about a quarter of the nation's health care expenditures.[l] Federally-supported research on health services was confined to studies related to particular federal programs, either done or sponsored by the administering agencies, and research on groups with diseases of interest to the Public Health Service and the National Institutes of Health. Legislation of the 1960s greatly extended the federal government's involvement in health care and changed the nature of its responsibili- ties. During the Lyndon Johnson Administration, the federal government adopted the view that such matters as poverty, housing, and health care were national problems that required national solutions.~2] This perspective was expressed in a series of legislative enactments that established many programs aimed at eliminating the hardships of poverty, some of which provided funds for health care. Unlike previous federal assistance programs, however, many created in the early 1960s called for direct and almost total federal funding and administration. Programs such as those for community action, demonstration cities, and neighbor- hood and migrant health vastly increased requirements for intragovern- mental coordination and information for their management. The needs became more acute in the mid-1960s, when the federal government enacted Medicare and Medicaid, and expanded community health planning under the Regional Medical Programs and Comprehensive Health Planning efforts. Following the implementation of Medicare and Medicaid, rising health care costs became a national issue whose consequence were strongly felt by the federal government. By 1968, federal spending for health care had reached $15 billion--a five-fold increase over the expenditures of 1960--and accounted for a quarter of all expenditures for health care in the United States and two-thirds of all public spending.~3]

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77 Because most of these monies were being spent under the Medicare and Medicaid programs to purchase health services through the private sector, attention turned to features of the nation's health services industry that accounted for rapidly increasing costs of health care. The 1967 report of the National Advisory Committee on Health Manpower attributed the cost problems to organizational and managerial deficien- cies within the industry.~4] Scattered responsibilities for categorical federal health care delivery programs, combined with rising health care costs, led to recommendations for a federal agency to coordinate the government's research efforts and to discover ways of improving the performance of the nation's health care industry. In his 1967 Health and Education Message to the Congress, President Johnson ordered the creation of such an agency in the Department of Health, Education, and Welfare. Objectives and Functions In its planning for the National Center for Health Services Research and Development (NCHSR&D), the DREW had commissioned a panel to recom- mend functions and organization arrangements. Its report, issued in mid-1967, recommended a national health services research program to provide fundamental knowledge to facilitate unrestricted access to optimal health care at the lowest sound costs (and) to foster within the health care system a sustaining capacity for timely and ade- quate adaptation and self-adjustment in response to changing needs and demands.~5] The report went on to identify immediate goals, which were adopted in most essential details as the program for NCHSR&D: --to improve the quality and efficiency of health care services through the application of advanced personnel utilization, technological innovations, and management methods of demonstrated value and effectiveness; --to survey and analyze the present state of the health system, searching for naturally occurring improvements; --to devise and test advanced health care delivery con- cepts and systems;

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78 --to develop resources of personnel and knowledge in the field of health services research and develop- ment, and to foster within the Center the capacity to plan, define, and skillfully guide extensive programs of health research and development; --to provide scientific data, analyses, and forecasts for consideration in planning and formulating policies affecting health services and health services research and development; - to foster the widespread development of resource (sic) and development capabilities in universities and other institutions and agencies; --to seek actively to motivate and actuate the applica- tion and installation of advanced concepts and systems of health service management; and --to develop information systems providing data rele- vant to health services research and development.~6] These goals were reflected in NCHSR&D's statement of program concerns submitted to the Congress in 1969.~7] The Center was to: --be a resource to the federal government by assembling and disseminating information about health services and health services research from the United States and abroad, and assisting other federal agencies to plan, establish priorities, and cooperate in joint endeavors; support through its extramural grants program study of the organization and financing of health care, use of personnel and resources, and other funda- mental problems in the health care industry; --develop operational definitions and knowledge about preconditions for the establishment and maintenance of effective and efficient health services; --encourage demonstration and testing of innovative approaches to health services delivery and manage- ment by

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79 extramural support of projects initiated by persons in health care institutions, and large-scale interventions designed by NCHSR&D staff; --develop the nation's capacity to conduct research and development by subsidizing training in health services research, and supporting centers for research and development located in universities and health care institutions. As NCHSR&D's programs developed, each of these functions was intended to contribute to its principal strategy of health services development. Reflecting the engineering and rationalistic research and development approaches of the aerospace industry and program planning and budgeting applied to the management of complex systems, NCHSR&D adopted a strategy of active intervention to develop and test innovations in the health services industry. This approach was manifested in several large-scale research and development projects begun in the early 1970s.~8] NCHSR&D's program in health manpower financed the training of former medical corps- men and other ancillary personnel; its efforts to improve the quality of health services led to the Experimental Medical Care Review Organiza- tions; several projects were initiated to facilitate the collection and use of health services information by state and local planning agencies; and its Experimental Health Services Delivery Systems program was aimed at developing and testing new forms of local and state organizations to consolidate the planning and management of community-wide health services delivery systems. Fran 1970 to 1973, these and other developmental efforts accounted for nearly half of the monies disbursed by NCHSR&D for new activities. Organization When NCHSR&D was created in 1968, it was placed in the newly created Health Services and Mental Health Administration (HSMHA) of DREW. NCHSR&D was given no explicit Congressional authorization,* and its *NCHSR&D's activities were authorized under Sections 301 and 304 of the Public Health Service Act.

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80 personnel and portfolio of research projects were assembled from other DREW agencies. Few persons who came to the Center had previous ex- perience in health services research, and few of the continuing projects inherited by the new agency dealt with important questions in health services. These beginnings greatly compromised the Center~s ability to carry out its mandated functions. HSMHA was established in 1968 to combine under a single administration DHEW's various health services delivery, planning, and research pro- grams.* As NCHSR&D was located at an equal organizational level with each of HSMHA's other agencies, it had no direct authority to coordinate their research and development activities. Attempts to do so through NCHSR&D's Experimental Health Services Delivery Systems program met with resistance that prevented cooperative interagency funding of local projects, and most agencies pursued the research and development programs they had developed before coming to HSMHA, paying little attention to NCHSR&D's offers of assistance. The problems NCHSR&D encountered within HSMHA were compounded in its efforts to provide coordination and assistance to other federal agencies involved in health services. HSMHA had no official authority over other DREW programs, such as those in the National Institutes of Health, the Social Security Administration (Medicare) and the Social Rehabilitation Service (Medicaid), or those of other executive departments and agencies (e.g., the Office of Economic Opportunity, the Veterans Administration). NCHSR&D's bureaucratic isolation from operating federal health services programs, which were unwilling to transfer or delegate research and development activities to the new agency, led NCHSR&D to assign rela- tively low priority to intragovernmental assistance and coordinating functions. Constrained by the small size of its initial budget and the heterogeneity of its staff and projects, the agency turned instead to developing its own research and development efforts. This involved redirecting emphases of the various grants and contracts the agency had inherited from other agencies and establishing new priorities and funding mechanisms more in keeping with NCHSR&D's own objectives. To accomplish this, NCHSR&D adopted the principal organizational features of the National Institutes of Health. A council provided advice on priorities and general oversight of the Center's activities. Experts from outside the federal government were appointed to study section panels to review the scientific and technical merits of *Initially, these included the Indian Health Service, Federal Health Programs Service, Community Health Service, National Institute of Mental Health, National Communicable Disease Center, Health Facilities Planning and Construction Service, Regional Medical Program Service, National Center for Health Statistics, and NCHSR&D.

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81 proposals submitted to the agency* and to advise NCHSR&D staff on health services research needs and priorities. Based in part on earlier recom- mendations of the Health Services Research Study Section' NCHSR&D expanded its program to support the creation of centers for health services research and development in selected universities and health care settings. The Center's programs and internal organization evolved into two largely distinct sets. One involved the solicitation, review, funding, and management of investigator-initiated grants and contracts that supported studies and research and development in a variety of subject areas. The other employed NCHSR&D staff in developing and managing the agency's large-scale research and development activities, which during the Center's formative years increasingly dominated its attention and budget. 1970 to the Present Location The National Center's location in the federal government and its pro- gram emphases have changed several times since its creation. In 1973, as part of a general reorganization of the Public Health Service, HSMHA was abolished and replaced by two new administrative organizations. The Public Health Service's delivery programs were combined under the Health Services Administration, and the National Center** was placed in the Health Resources Administration, along with the National Center for Health Statistics, the newly created Bureau of Health Planning and Resources Development (BHPRD),*** and the Bureau of Health Manpower (transferred from the National Institutes of Health). *Four study sections were chartered: Health Services Research, Health Services Demonstrations, Health Care Technology, and Health Services Research Training. **Renamed briefly the Bureau of Health Services Research, the Bureau of Health Services Research and Evaluation, and, finally, the present National Center for Health Services Research. ***Established under P.L. 93-641 to combine and replace authorities of the Hill-Burton, Comprehensive Health Planning, and Regional Medical programs.

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82 Officially, NCHSR's missions remained unchanged, including its role as a coordinating and assistance resource within the federal government. In fact, however, the 1974 reorganization further impeded the agency's possibilities of influencing research and development within the Public Health Service by imposing an additional bureaucratic layer between the National Center and the service delivery programs in the Health Services Administratione In an effort to remedy this organizational problem, NClISR and its sister agency, the National Center for Health Statistics, were elevated In 1977 to the Office of the Assistant Secretary for Health of DREW, where they currently are under the supervision of the Deputy Assistant Secretary for Health Policy, Research, and Statistics. This move took place only a few months before the committee began its assessment, and too little time has elapsed-for an evaluation of its effects on the Center's pro- grams and functions. Budget Over the course of the National Center's history its budget and program priorities have undergone major changes. By 1970, NCHSR had reached its present personnel complement of about 200 and, as shown in Table 7, had a budget of $37.4 million. Available funds increased annually to a peak of $56.1 million in 1972, after which they declined steadily in actual and real terms. The Center's 1978 budget represented less than 40 percent of its purchasing power in 1970.* Coincident with the trend in total budget are important changes in com- ponents of spending, which reflect changes in the Center's priorities and constraints on its budget imposed by DHEW and the Congress. During the Center's formative years, its programs were influenced greatly by large-scale, agency-initiated developmental projects funded largely by contracts. The effects of these projects are shown at the bottom of Table 7 in the relative portions of funds spent by contract. As these efforts were phased out in 1974 and 1975, the use of contracts diminished relative to grant-supported research from more than 40 percent contract in 1970-1972 to 17 percent in 1978. The shift from large-scale developmental projects left a larger por- tion of the Center's declining budget to support research. The great majority of funds employed to finance the Experimental Health Services Delivery System, the Federal-State-Local Data Systems and other large- scale projects were devoted to developmental activities and relatively *These budget figures refer to funds available for support of research and training programs and do not include costs of administering the agency.

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83 TABLE 7 NATIONAL CENTER FOR HEALTH SERVICES RESEARCH BUDGET BY CATEGORY, FISCAL YEARS 1970-1978 (in thousands of dollars) 1970 1971 1972 1973 1974 1975 1976 1977 1978* Extramural Research and Development 32, 940 46, 618 51 ,118 41 ,150** 39, 705 32, 905 18, 600 17, 900 18, 000 (%) (88) (91) (91) (90) (92) (92) (72) (74) (75) Grants 15,283 25,009 28,050 24,529 27,459 27,905 16,100 14,900 15,000 (%) (41) (49) (50) (55) (64) (78) (62) (62) (62) Contracts 17,657 21,609 23,068 15,121 12,246 5,000 2,500 3,000 3,000 (%) (47) (42) (41) (34) (28) (14) (10) (12) (13) Training 4, 500 5, 000 5, 000 4, 700 3, 400 2, 000 900 100 (I) (12) (9) (9) (10) (8) (6) (3) (*) Int ramural Re search (%) - 1,000 6,500 6,039 6,000 - (2) (25) (25) (25) Total $37,440 51,168 56,118 45,850** 43,105 35,905 26,000 24,039 24,000 ( %) (100 ) (100 ) (100 ) (100 ) (100 ) (100 ) (100 ) (100 ) (100 ) Contracts as a of Extramural Research 54% 46 45 31 31 15 13 17 17 *Amount req ues ted . **Includes special appropriation of $1.5 million for research on emergency medical services. Source: "Justification of the Budget Estimates, Departments of Labor and HEW Appropria- tions, " Hearings Before A Subcommittee of the Committee on Appropriations, House of Representatives: 91st Con., 2nd sees., Part 2, p. 681; 92 Con., 1st Sess., Part 2, p. 322; 92nd Con., 2nd Sess., Part 3, p. 556; 93rd Cong, 1st Sess., Part 3, p. 400; 94th Cong., 1st Sess., Part 2, p. 808; 94th Cong., 2nd Sess., Part 3, p. 628; 95th Cong., 1st Sess., p. 644; Hearings Before Subcommittees of the Com- mittee on Appropriations, United States Senate, Supplemental Appropriations for Fiscal Year 1975, 93rd Cong., 2nd Sess., on HR 16900, p. 143.

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84 little to evaluation and other research. When these developmental costs are subtracted from the Center's 1970-1973 budgets, approximately $35 million remains for support of the types of research and smaller-scale demonstration projects that comprise the Center's current programs and priorities. Hence, the decline in the Center's total budget after 1973 is substantially overstated if the agency's current priorities and strategies are taken as the touchstone. The Center's support for research training decreased after 1973, following a decision by the Office of Management and Budget to suspend the program. The Center has not been allowed to reinstate it, despite the existence of provisions for training in the Center's authorizing legislation. Following 1973, expenditures for training met obligations for programs incurred earlier, but no new programs were permitted. By 1978, all support for training programs had ceased. In 1974, the Center received its first explicit legislative authority under the Health Services Research, Health Statistics, and Medical Libraries Act (P.L. 93-353), which amended Sections 301, 304, and 308 of the Public Health Service Act. These amendments directed the National Center to allocate a minimum of 25 percent of its annual budget to intramural research and to establish centers for health services research. By 1977, both provisions had been implemented, with- the result that already reduced monies for new extramural research grants and contracts were further reduced. As shown in Table 8, the Center now obligates a total of about $10 million annually to the intramural and centers programs. This, combined with obligations for continuing extramural projects, accounted for 88 percent of the Center's budget in 1978, leaving only $2.8 million for new extramural projects. Priorities The priorities established early in the National Center's history empha- sized large-scale, agency-initiated demonstration programs funded largely through contracts. By 1975, however, the present pattern of funding primarily investigator-initiated research and demonstration via grants had become established. The shift from the large-scale developmental projects to smaller-scale demonstrations and research was occasioned in part by the enactment of several programs similar to those NCHSR had been testing and by the Center's declining budget. For instance, the Center's Experimental Medical Care Review Organizations (EMCRO) program dealt with prototypes of the Professional Standards Review Organizations created by 1972 amendments to the Social Security Act; its Experimental Health Services Delivery Systems (EHDS) projects, which attempted to test the feasi- bility of local management of health care programs by community organi- zations, was terminated with the enactment of the National Health Planning and Resources Development Act of 1974.

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85 TABLE 8 TOTAL FUNDS AVAILABLE, CONTINUING OBLIGATIONS, AND REMAINING FUNDS, THE NATIONAL CENTER FOR HEALTH SERVICES RESEARCH, FISCAL YEARS 1976-1978 Fiscal Year 1977 1978* - (in millions of dollars) Total Funds Available Obligations $24.0 $24.0 Continuing Projects 11.6 10.9 Intramural Program 6.0 6.0 Centers Program 3.6 4.3 Remaining Funds 2.8 2.8 *Amount requested Source: "Justification of the Budget Estimates, Departments of Labor and HEW Appropriations," Hearings Before a Subcommittee of the Com- mittee on Appropriations, House of Represen- . atives, 95th Congress, 1st Session, Part 4, p. 645. The Center's current priorities reflect its attempts to deal with major policy issues and to coordinate the dissemination of findings from health services research. After a series of meetings involving persons from government, the health care industry, and the health services research community,[9] the Center has identified nine priority areas for research and demonstration.tl0~: Quality of care Productivity and cost of inflation Health care and the disadvantaged Health manpower Health insurance Planning and regulation

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92 The conclusion, even when based on history, that a general-purpose research agency such as the National Center is unable to effect coordi- nation among federal agencies overlooks the weaknesses of the positions that the agency has occupied within the federal structure and its present status in the Office of the Assistant Secretary for Health (CASH). The Center has never before been located within the office of officials with authority over operating programs. During its first six years of existence, the Center was below the Office of the Administrator, on line with other agencies within HSMHA. Following the 1974 reorganization of the Public Health Service it resided under the Office of the Administrator of BRA, separated bureaucratically from the Public Health Service's service delivery agencies. Its move to CASH in 1977 placed it bureaucrati- cally above all Public Health Service programs, which account for about 60 percent of the federal government's spending for health services research. From this position the Center may be better able than before to influence and assist other agencies' health services research agendas and projects. From its review of the history of the National Center for Health Services Research, the Center's current priorities and functions, and potential for effecting greater coordination of the health services research activities of the Public Health Service, the committee recom- mends that the National Center for Health Services Research should be maintained as a general-purpose health services research agency within the federal government. Further, the committee recommends that the Center's functions should be: . to sponsor health services research and research in related disciplines through a program of extra- mural, investigator-initiated grants and contracts; to conduct intramural research; to sponsor through a program of extramural grants and contracts training in health services research and related disciplines; to monitor the development of knowledge relevant to health services research, and disseminate this knowledge; to assist other federal agencies in developing health services research priorities and programs and in designing and executing evaluations of federal programs; and

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93 to facilitate the development of the health services research capacities of non-federal organizations and agencies. The committee believes that one of the National Center's principal missions should be to conduct and sponsor synthesizing research aimed at filling gaps in research and knowledge. Therefore, the Center's purview must not be limited to particular types of questions. Indeed, the Center should be encouraged to pursue research on issues that are related to the principal focuses of operating agencies and should be accorded the opportunity to be designated as the lead agency in coordi- nating and developing important areas of health services research that are not tied directly to other agencies' missions. Accordingly, the committee recommends that the purview of NCHSR should not be constrained by , . specific federal policies or operating programs and . . . . _ .. should encompass research on dental, mental, and ~ . . . . . . . _ nursing services. Although the recommendation regarding the Center's functions are similar to those established for the agency at its outset, the committee is mind- ful of the fact that they cannot be performed adequately under current circumstances. In retrospect, the committee believes that initial expec- tations about the Center's objectives were unrealistically optimistic, especially in light of the meager resources devoted to them. Declining budgets and limitations on the Center's ability to recruit personnel needed to address each of its missions have placed the agency under doubly difficult constraints. If these constraints are not relaxed, the Center will be forced to continue to entirely suspend important functions or to pursue them with less vigor than they warrant. Therefore, the committee recommends that DREW review the personnel and budgetary require- . .. . . . . . . meets for each of the functions identified in the _ _ _ committee's recommendations and provide the NCHSR . . . . with the resources required to perform them. . . Health Services Research Training Among the functions recommended above for the National Center is the support of programs for training in health services research. Early in its history, the Center provided grants for this purpose, and its current legislative authority permits the support of training. However, since 1973 DREW has rejected the agency's requests for funds to re-establish this program.

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94 The committee did not review in depth issues relating to training in health services research because of the existence within the Academy of the Commission on Human Resources panel on health services research, which was created specifically for that purpose. The Commission was established pursuant to provisions of the National Research Service Award Act of 1974 (P.L. 93-348), which authorized training in biomedical and behavioral research and directed DREW to request the Academy to conduct studies of needs for biomedical and behavioral research person- nel. One of the Commission's panels has focused on training needs for health services research. The committee reviewed the Commission's reports and generally agrees with its findings and recommendations.[ll] The committee is particularly concerned about the potential long-term effect of-the lack of support for training on the supply of qualified persons to engage in health services research. Accordingly, the committee endorses the Commission's recommendations that the National Research Service Award Act of 1974 be amended to incorporate training in health services research and that the National Center be provided the opportunity to develop and maintain a training program. Specifically, the committee recommends that the NCHSR be permitted to re-institute its _ support of health services research training, - based on a careful review of the most appropriate mix of disciplines and levels of training deserving - of support. Centers Program On advice frog the Health Services Research Study Section, a program to support health services research and development center grants was launched in early 1968 by the then Division of Medical Care Administration and subsequently expanded by the newly created National Center for Health Services Research and Development. In all, eleven centers received sup- port through competitive grants. These grants were awarded on the basis of the scientific and technical merit of applicants' proposals and the promise of their settings to provide opportunities for the development and testing of innovations in health services organization and delivery. Each of the centers was to emphasize research and development dealing with particular identified health services problems (e.g., health care tech- nology, ambulatory care). As originally conceived, centers were to serve several purposes. In addition to conducting research and demonstrations, they were to provide assistance to their respective institutions and communities in health services research and development, to provide a setting in which to train researchers, and, ultimately, to become permanent, self-sustaining parts of their parent organizations.

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95 As they developed, few of the original centers fulfilled these expectations. Needs for funds to survive and to keep their staffs intact militated against their pursuing only projects falling within their areas of emphasis.[l2] These difficulties, compounded by changing priorities of federal agencies supporting health services research, led several centers to develop a spectrum of discrete projects, often bearing little identifiable relationship to a systematic research and development pro- gram. The centers program was also troubled by uncertain relationships between the centers and the National Center. Center directors were inclined to view their organizations as largely independent of the National Center's priorities and agendas. On the other hand, pressures on the Center from DREW and the Congress to address matters of national importance often led the National Center to assess centers in terms of their contributions to its research and development agenda. As the centers were brought up for periodic review, study sections recom- mended discontinuation of all but two of them. Pursuant to provisions of P.L. 93-353, directing the National Center to reinstate its centers programs, the two remaining centers and six new ones were funded, three of which were designated as special emphasis centers e The current program differs from the earlier ones in two important respects. With the exception of the special emphasis centers, awards to centers of about $250,000 per year in direct costs are intended to be used primarily for core support, not as monies to support research. While a portion of these funds may be used to design projects and to support small-scale, exploratory and feasibility studies, their princi- pal purposes are to provide at least partial salaries for a full time director and associated staff and to cover administrative costs. With this relatively meager support, the centers are expected to engage in several activities, including research, technical assistance to local health care institutions and agencies, and providing opportunities for training. As in the situation of the National Center itself, expectations placed on the centers greatly exceed their resources. The centers, other than those having a special emphasis, must seek outside support for their research programs, which means that few can afford to selectively pursue projects that fit into a coherent programmatic effort. These circum- cumstances greatly detract from the National Center's ability to evaluate their programs and contributions. Ultimately, the National Center finds itself accountable for research done by centers over which it has little control. The centers program also raises the issue of how the National Center's scarce resources should be used. While the committee recognizes the importance of fostering centers of excellence in health services research and providing them with stable support, the benefits of this program to the health services research community must be weighted against the share of available research funds it consumes. As noted earlier, the centers program is a fixed annual obligation of approximately $4.0 million

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96 In 1978 this represented one-sixth of the National Center's total budget and nearly one-third of the funds remaining after continuing and intra- mural obligations were met. In view of the uncertainty surrounding the centers program and of the limited funds available to support investigator-initiated health services research, the committee recommends that legislation authorizing the National Center for Health Services Research be amended to strike the requirement that the Center sup- port centers for health services research. - The National Center should be permitted to support center grants if a consensus is reached that the program complements the Center's overall mission and the evolution of the field as a whole. Awards of center grants should be based on review by peers of scientific and technical merits of proposed studies, their coherence as a set, qualifications of principal investigators and staff, and other features that are relevant to applicants' abilities to complete the proposed work, rather than the existence of a legislative mandate. Intramural Research The committee recognizes that the National Center for Health Services Research requires a strong intramural research effort to attract and keep qualified researchers. Such persons are needed to assist other federal agencies in their health services research activities; to develop NCHSR priorities; to monitor health services research studies and literature; to identify, summarize, and critique methods and find- ings; and to conduct studies that are best done within the government. However, the committee is concerned about two features of the present intramural program of the Center. The committee's first concern has to do with its legislatively mandated minimum budget. Public Law 93-353 requires the National Center to devote not less than a quarter of its budget to intramural research. The requirement is troublesome for at least two reasons. Because of the practice of establishing separate ceilings for budget and personnel, the availability of funds to conduct intramural research on a topic that may be of critical importance provides no assurance that the work will be done or, if done, will be done well. Spending the dollars wisely is dependent upon the availa- bility of appropriately trained, experienced investigators. Despite same notable exceptions, the National Center has had difficulty in securing senior researchers of the stature required for a viable and respected intramural research program. A partial solution has been to augment

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97 existing staff with visiting researchers under provisions of the Intergovernmental Personnel Act or, for less senior persons, the Service Fellows Program. A more lasting solution would be to revise civil service procedures and to eliminate dual ceilings. The effects of a budgetary minimum for intramural research are further compounded by reducing the resources that would otherwise be available for investigator-initiated extramural research. In 1978, the intramural reserve was nearly three times the monies available to support new extramural research. In such circumstances of scarce resources, the committee believes that it is inappropriate to require the Center to devote nearly $6.0 million to intramural research when other meritorious uses could be made of these funds. In view of the stringent fiscal and personnel constraints faced by the National Center for Health Services Research, the committee recommends that the legislation mandating the intramural research _ program of the National Center for Health Services Research be amended to strike the language re- quiring the Center to allocate not less than twenty-five percent of its budget to intramural research. Organizational Location Of The National Center Over the past decade, the National Center has occupied three different locations within the federal government. It has been situated in its present location in the Office of the Assistant Secretary for Health (DASH) for less than one year. In light of Congressional debate about the appropriate organizational locus for the Center that occurred during the course of this study, the committee reviewed several options. These include leaving the Center in its present GASH position; relocating it in the National Institutes of Health; re-creating it as a free-standing agency in the Public Health Service; and re-creating it as a free-standing agency in the Office of the Secretary of the Department of Health, Education, and Welfare e The associated strengths and weaknesses of each are presented below. Many of the arguments arise from a fundamental dilemma involving the need for organizational and political authority to achieve coordination of research priorities versus the need to insulate the Center from political pressures that might inappropriately influence its research priorities and interpretation of research findings. Option #1 - Leave the Center in the Office of the Assistant Secretary for Health

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98 Pro: 1. Located above all PHS agencies and better able to coordinate and assist other health services research activities. 2. Greater leverage in securing increases in budget and staff positions. 3. Greater ability to enlist support of Assistant Secretary for Health in negotiating with non- PHS sponsors of health services research. Enhanced likelihood that research findings will be synthesized and channeled to policy- makers when appropriate. 5. Re-location too disruptive, given the recent placement in GASH. Con: 1. Unable to influence directly the health services research activities of the Health Care Financing Administration and other non-PHS agencies. Close proximity to persons responsible for policy initiatives heightens the potential for politicization of research agenda and findings. Option #2 - Relocate within NIH Pro: 1. Heightened visibility and status by association with widely respected institution with tradition of supporting high quality research. Greater protection from political influences. 3. Enhanced likelihood of stimulating research to fill large gaps between clinical and health services research. 4. Potential salutary effect on health services research components of NIH activities. Con: 1. Removed from operating agencies within PHS. Still unable to influence directly the health services research activities of HCFA and other non-PHS agencies.

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99 3. NIH traditionally has not been interested in health services research; Center might suffer from neglect. Option #3 - Re-create as free-standing agency in Public Health Service Pro: 1. Heightened visibility and status. 2. Potential for creating new focus for health services research free from limitations of the past. 3. Greater protection from political influences. Con: 1. On line with (rather than above) other agencies in PHS. 2. Still unable to influence directly the health services research activities of the HCFA and other non-PHS agencies. Given resource constraints, a fledgling organiza- tion is unlikely to acquire the necessary bureau- cratic infrastructure to survive. Option #4 - Re-create as free-standing agency in the Office of the Secretary, DHEW Pro: 1. Heightened visibility and status. 5. Potential for creating new focus for health services research free from limitations of the past. Located above all DHEW programs, including HCFA; better able to coordinate research priorities and integrate and synthesize research findings. 4. Potential to improve quality of research and main- tain accountability to and for the entire field. Enhanced likelihood that research findings would be channeled to policymakers when appropriate. Con: 1. Creates distance between researchers and other DHEW agencies that lessens the likelihood that research will be responsive to needs of operating programs.

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100 2. Close proximity to persons responsible for policy initiatives heightens the potential for politici- zation. After considering the issue of the location of the National Center, the committee concluded that there are no compelling grounds for recommend- ing specific organizational changes. As the Center has experienced frequent and significant disruptions from previous reorganizations, the most recent of which occurred within the past year, the committee believes that further changes of location would create additional difficulties. The committee notes that the Center's present location within GASH provides the possibility for enhanced organizational and political visibility and authority. This may, however, lead to inappro- priate politicization of its research priorities, agendas and roles. As the Center has been in CASH for only a limited period, it is too early to determine whether its current location is, overall, a desirable one. Therefore, the committee recommends that the National Center for Health Services Research remain in its present location in the Office of the Assistant Secretary for Heal_ and that the effects of these arrangements on the various functions and priorities of the Center be evaluated after a suitable interval, perhaps five years, to determine whether further reorganization is warranted.

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101 REFERENCES 1 2 3 4 5 6 7 8 Barbara S. Cooper, "National Health Expenditures," Research and Statistics Note (November 1969), Table 2,3. James L. Sundquist and David W. Davis, Making Federation Work (Washington, D.C.: The Brookings Institution, 1969.) Barbara S. Cooper, "National Health Expenditures," Research and Statistics Note (November 1969), Table 2,3. Report of the National Advisory Commission on Health Manpower, Volume I (Washington, D.C.: U.S. Government Pringing Office, 1967), 2. Task force report on the National Center for Health Services Research and Development submitted to the Assistant Secretary for Health and Sciencific Affairs, Department of Health, Education, and Welfare, 24 July 1967, p. I-4. Ibid., pp. I-4-5. "Justification of the Budget Estimates, Depts. of Labor and HEW Appro- priations," Hearings Before A Subcommittee of the Committee on Appropriations, House of Representatives: 91st Con., 2nd Session, Part 2, p. 322; 92nd Con., 2nd Session, Part 3, p. 556; 93rd Con., 1st Session, Part 3, p. 400; 94th Con., 1st Session, Part 2, p. 808; 94th Con., 2nd Session, Part 3, p. 628; 95th Con., 1st Session, p. 644; Hearings Before Subcommittees of the Committee on Appropriations, United States Senate, Supplemental Appropriations, for fiscal year 1975, 93rd Con., 2nd Session on HR 16900, p. 143. Paul J. Sanazaro, "Federal Health Services R & D Under the Auspices of the National Center for Health Services Research and Development, Chapter VI in E. Evelyn Flook and Paul J. Sanazaro, Health Services Research and R & D in Perspective (Ann Arbor: Health Administration Press, 1973), ppe 150-83.

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102 9 10 11 12 Daniel M. Fox, "The Development of Priorities for Health Services Research: The National Center, 1974-1976," Milbank Memorial Fund Quarterly/Health and Society 54 (Summer 1976~: 237-248. , . , U.S. Department of Health, Education, and Welfare, Public Health Service, Forward Plan for Health, FY 1978-82, DREW Pub. No (05) . . . . . . .. . . . . 76-50046 (August 1976). Commission on Human Resources, National Research Council, Personnel Needs and Training for Biomedical and Behavioral Research: 1977 . . ~ . . . . . . . . . .. . . Report (Washington, D.C.: National Academy of Sciences, 1977), Vol. 1, 128-149. Jere A. Wysong and Edward G. Ludwig, "Health Services Research Centers: The Concept, Experience, and New Legislation," Journal of Health Services Research 9 (Fall 1974~: 183-194.