´óÏóÊÓƵ

Below we describe in more detail the individual HSR and PCR portfolios of the federal operating divisions in-scope of the study, including both extramural research (i.e., grant and contract awards to nonfederal entities to conduct research) and intramural research (i.e., research conducted primarily by agency staff). Interview and TEP experts commented on the role of intramural research in allowing agencies to address research questions on timely issues, provide scientific design and analytics to support research infrastructure—such as large national data sets—used by the research community to conduct HSR and PCR, and improve the research skills and retention of highly qualified agency staff needed to supervise extramural research funding programs. As noted above, these descriptions are based on expert information from the study’s TEPs and stakeholder interviews, as well as documentary sources as indicated.

Administration for Community Living

ACL serves as the federal agency responsible for increasing access to community supports, while focusing attention and resources on the unique needs of older Americans and people with disabilities across the life span (Administration for Community Living, 2019a). Most of the ACL’s extramural funding consists of service grants that do not include research as defined by this study. However, the agency’s NIDILRR operates several programs that fund research projects with health care-related components (Administration for Community Living, 2019b). This portfolio includes Model Systems Programs that fund centers of excellence to provide and evaluate comprehensive, evidence-based models of care and support for individuals in communities who have spinal cord, burn, or traumatic brain injuries (Model Systems Knowledge Translation Center, undated). The NIDILRR portfolio also contains extramural funding of research on the implementation and effects of health policies on community living of people with disabilities of all ages, rehabilitation research centers that include studies of health services and financing, and grants on health technology that include research on telehealth to support people with disabilities living in community.

´óÏóÊÓƵ

´óÏóÊÓƵis the only federal agency that has a congressional authorization to generate HSR with a mission to do so across the U.S. healthcare system, including how to make health care safer, higher quality, more accessible, equitable, and affordable (42 CFR 67.13). ´óÏóÊÓƵalso has a statutory charge to serve as the lead federal agency for primary care practice research. Although ´óÏóÊÓƵhas not received targeted appropriations for this latter mission, the agency funds and disseminates research on primary care systems and innovations, including the nature of primary care as the usual source for addressing personal health care needs, the management of commonly occurring and undifferentiated clinical problems, and the continuity and coordination of health services (42 U.S.C. 299 et seq). The agency also hosts the National Center of Excellence for Primary Care Research, which provides evidence, practical tools, and other resources to improve primary care (´óÏóÊÓƵ, undated-i). A key objective of the agency is not only to generate evidence from HSR and PCR that improves care, but also to ensure the evidence is known and used, particularly by health care delivery systems and providers (´óÏóÊÓƵ, 2019e).

A hallmark of AHRQ-sponsored research noted by stakeholders and TEP experts is its focus on systems-based improvement across the spectrum of care settings and populations in the U.S. health system. AHRQ’s research portfolio is not limited by type of disease, condition, patient populations, or payment systems. Even when AHRQ-sponsored research focuses on specific conditions (e.g., HIV/AIDS, diabetes, or other chronic conditions) or vulnerable populations (e.g., low income, minority, elderly, women, and children), it aims to understand both the specific factors affecting how that care is provided in real-world delivery systems and more general evidence on the process of health service improvement.

AHRQ’s research portfolios are organized around key health care system inputs and outcomes. One of the largest portfolios has focused on quality of care and patient safety. Patient safety became a particular emphasis after Congress directed ´óÏóÊÓƵin 2001 to invest significant resources in this area (Senate Report 106-293, 2002), which has included research on the causes of and effective strategies to reduce medical errors and harms, such as healthcare-associated infections, adverse drug events, and preventable hospital readmissions (´óÏóÊÓƵ, 2018). The agency additionally has focused on access to and disparities in care, such as through its annual National Healthcare Quality and Disparities Report on differences in care by race, ethnicity, income, and other social determinants of health (´óÏóÊÓƵ, 2019f). Other portfolios include research programs on delivery system organization and markets, and on health care financing and costs, although some research stakeholders perceived the latter topics to have declined in relative emphasis by the agency over time. The agency also has maintained a long-standing portfolio of research on HIT implementation to improve care.

On the topic of quality and patient safety, ´óÏóÊÓƵhas invested particularly in research on measurement to facilitate improvement of health services. This research has included development of specific safety and quality-of-care indicators for organizations and providers to monitor and target improvement efforts, as well as instruments to measure organizational capacity supporting safety and quality improvement, such as the Survey of Patient Safety Culture (SOPS). Over the past two decades, ´óÏóÊÓƵalso has funded development of the Consumer Assessment of Healthcare Providers and Systems (CAHPS), a series of surveys for patients to rate experiences with hospitals, other providers, and health plans (´óÏóÊÓƵ, 2019a).

Beyond measurement, ´óÏóÊÓƵresearch has a strong emphasis on implementation tools, methods, and evaluation. ´óÏóÊÓƵfunds a range of toolkits that combine evidence-based care practices with organizational change packages tailored to specific settings, as well as projects to implement and evaluate the dissemination of these tools across health care delivery systems at the local, state, and even national levels. Stakeholders and TEP experts, including researchers, delivery leaders, state policymakers, and other research users, noted the particular focus of this portfolio on understanding implementation and wider scale-up of improvement practices, and developing methods for conducting implementation evaluations.

Stakeholders also commented on AHRQ’s unique role in synthesizing and disseminating scientific evidence on HSR and PCR. Most notably, the agency funds evidence-based practice centers (EPCs) that conduct systematic reviews and syntheses of the scientific literature on a wide spectrum of clinical and health services topics (´óÏóÊÓƵ, 2019d). ´óÏóÊÓƵand the evidence-based practice centers also support the U.S. Preventive Services Task Force by providing the resources—scientific, administrative, and dissemination— in its mandate under the Affordable Care Act to make independent recommendations about clinical preventive services (U.S. Preventive Services Task Force, 2018).

AHRQ’s PCR portfolio has varied across all the main areas described above. Stakeholders and members of both the PCR and HSR TEPs noted the agency’s emphasis on studying primary care from a systems perspective to understand its unique nature and functions within the health care system, including managing multiple and often undifferentiated conditions, and its potential to coordinate care with other health and related community services. For example, ´óÏóÊÓƵfunded some of the earliest studies to define and synthesize evidence on new models of primary care, such as PCMHs. Similarly, it has funded research on roles of different health professionals in team-based models of care, as well as issues of clinician wellness and burnout. Over time, AHRQ’s PCR program has evolved from developing capacity for conducting PCR in practice settings and individual studies to improve management of chronic and other common primary care conditions (e.g., the Practice-Based Research Networks) to primary care transformation and mechanisms for moving evidence-based care into practice, such as through the Transforming Primary Care and the current EvidenceNOW initiatives (´óÏóÊÓƵ, 2015; ´óÏóÊÓƵ, undated-b).

In terms of AHRQ’s intramural research efforts, stakeholders and TEP experts noted the agency’s activities in three areas: analyses and reports on key HSR and PCR issues, dissemination activities, and systems for health delivery organizations to share patient safety data. While supported by technical contractors, ´óÏóÊÓƵstaff lead the development of the National Healthcare Quality and Disparities Report and other analyses, such as the state of primary care in the United States. Agency staff regularly produce conceptual and methods guidance, such as frameworks for defining and conducting PCR, and application of complex adaptive systems theory to health care research. Dissemination activities include the preparation and distribution of implementation toolkits developed by AHRQ-funded research projects, as well as dissemination of current HSR and PCR evidence such as evidence-based practice center reports and recommendations of the aforementioned U.S. Preventive Services Task Force. The agency also leads the analytic design and support for the Patient Safety Organizations program, which enables health care providers to uniformly report patient safety events and improve efforts to eliminate harm (´óÏóÊÓƵ, undated-f).

In addition, ´óÏóÊÓƵproduces and maintains several large databases and data repositories available to research and health care delivery stakeholders to facilitate improvement across the breadth of the U.S. health care system. Databases include the Healthcare Cost and Utilization Project (Healthcare Cost and Utilization Project, 2019), which contains the largest collection of longitudinal encounter-level hospital care data, and the Medical Expenditure Panel, the most complete source of data on the cost and use of health care and health insurance coverage in the United States (´óÏóÊÓƵ, undated-e). Data repositories produced and maintained by ´óÏóÊÓƵinclude a reporting and benchmarking database health care organizations can use for the Survey of Patient Safety Culture survey and the system for vendors to administer and report results of CAHPS surveys.

Office of the Assistant Secretary for Planning and Evaluation

ASPE advises the Secretary of HHS on policy development, coordinates the department’s evaluation, research, and demonstration activities, and manages cross-department planning. Integral to this role, ASPE conducts research and evaluation, policy analyses, and estimates of the cost and benefits of policy alternatives under consideration by the department or Congress (Assistant Secretary for Planning and Evaluation, undated).

ASPE’s research activities involving HSR and PCR are focused on informing policies related to specific federal programs and initiatives either at the department or operating division levels within HHS (U.S. Department of Health and Human Services, 2019). These requirements have drawn upon ASPE’s breadth of content matter knowledge and research capacity across the range of programs in HHS operating divisions and its ability to produce research on relatively short timelines to inform real-time policy decisionmaking.

ASPE determines its specific research foci in response to the HHS Secretary’s priorities, Congressional mandates, requests from other HHS operating divisions, and self-initiated projects. ASPE typically selects both short-turnaround and forward-thinking projects to build capacity for anticipated needs for which it can uniquely contribute value through expertise or the specific data sources and modeling capabilities it maintains for timely evaluation of health care trends and in response to immediate questions on HHS policy and program decisions. Other criteria for selecting research foci include its objectivity as an independent evaluator for agency-level programs and its availability of research resources relative to other agencies.

Over time, ASPE’s health care research portfolios have centered on access to care, health insurance coverage, health care costs and spending, behavioral health innovations, and health services for special populations, such as American Indians/Alaskan Natives (U.S. Department of Health and Human Services, 2018b). These foci are inclusive of the current Secretary’s four priorities—the opioid crisis, health insurance reform, drug pricing, and value-based care (U.S. Department of Health and Human Services, 2018a). ASPE’s focus on behavioral health and care for the American Indians/Alaskan Native population largely reflects research support it provides to SAMHSA and IHS, respectively, which possess limited in-house research capacity. ASPE also contributes to research and evaluation of programs in agencies that may have substantial research capacity when it can provide unique expertise and resources, such as projects for CMS that utilized an international drug price database that ASPE had previously acquired, its Transfer Income Model, or its evaluation expertise (U.S. Department of Health and Human Services, 2019).

Within PCR, a key research emphasis for ASPE has been on access to primary care services. Examples include evaluations of the National Health Service Corps to increase the primary care workforce in underserved areas (U.S. Department of Health and Human Services, 2019), of the ECHO telementoring platform to build primary care capacity in underserved areas (U.S. Department of Health and Human Services, 2018b), and of SAMHSA’s Primary and Behavioral Health Care Integration Grant Program to integrate primary care services into publicly funded, community-based behavioral health settings (Substance Abuse and Mental Health Services Administration, undated).

Other PCR topics have included primary care transformation (e.g., studying implementation of PCMHs in IHS facilities) (U.S. Department of Health and Human Services, 2018b) and perspectives of Medicaid programs and health centers regarding state telehealth policies (U.S. Department of Health and Human Services, 2019).

Much of ASPE’s research is conducted intramurally. Extramural research is funded through contract mechanisms. Decisions to conduct research internally or externally is based on the availability of the Office’s resources including staff, data, and contract funding.

Centers for Disease Control and Prevention

The mission of CDC is to protect the health of Americans by fighting disease and supporting communities and citizens in health promotion. To accomplish this objective, CDC conducts critical science and provides health information to understand and address threats to public health (Centers for Disease Control and Prevention, 2019). Interview and TEP participants noted that CDC has a broad public and population health focus that includes all people in communities—healthy as well as sick individuals, and whether or not they are engaged in the health care system. To fight disease and support health promotion, CDC organizes its research around disease states and health conditions, including both those that are communicable and noncommunicable. The agency’s research also emphasizes primary prevention (i.e., preventing the onset and reducing the incidence of disease) and secondary prevention (i.e., detecting disease early and preventing it from becoming worse) more so than tertiary prevention (i.e., managing the symptoms of a disease once it has progressed) which is the traditional focus of health care delivery systems.

As noted by federal and other interview participants, much of CDC’s research would not be considered HSR or PCR under the definitions of this study. Most of CDC’s extensive population of health and disease surveillance systems collect health outcomes data but generally do not monitor delivery of associated health care services. The CDC also funds many broad public health initiatives and community-based prevention programs that do not involve health care providers or systems. Several state and research interview participants similarly noted that CDC produces evidence-based recommendations and guidelines on prevention practices but typically does not fund research on the implementation of these practices in health care settings. CDC funds many public health and prevention delivery programs through cooperative agreements; however, the evaluations included in these agreements tend to be for program monitoring and accountability that would not be considered HSR or PCR under the definitions of this study.

Yet interview and TEP participants described several areas in which CDC’s research on population health outcomes measurement, surveillance and analysis and the evaluation of prevention services intersects with the health care system and HSR and PCR topics. Federal interview participants observed that the line between health care and public health prevention has begun increasingly to blur, particularly since changes in access to health care and the movement toward value-based care. For example, CDC has collaborated with CMS on projects such as the Million Hearts Campaign that incorporates both clinical quality improvement and community approaches to prevention of cardiovascular disease (Million Hearts, undated). Similarly, the CDC’s Comprehensive Tobacco Control Program includes the role of health insurance (e.g., coverage of cessation services) and health care providers (e.g., linking of patients to community resources) in the design and evaluation of the program (Centers for Disease Control and Prevention, 2014).

In addition to research on linking of patients within health care systems to public health interventions, CDC has focused on access to health care after an injury or other health incident experienced in a community setting (e.g., after an individual sustains a concussion) or a critical community event (e.g., following a public health emergency).

The intersection between CDC’s surveillance of population health outcomes and research on health care delivery has also increased. CDC research has for a while analyzed the extent and content of prevention services delivered, as well as disparities in prevention services and health outcomes. More recently, CDC surveillance systems and health outcomes measures have become progressively incorporated within efforts to measure health care quality. For example, CDC helped derive standardized indicators of HIV viral load that would be meaningful for CDC surveillance as well as CMS quality reporting and HRSA’s monitoring of the Ryan-White HIV/AIDS Program. The most notable such example discussed by federal, state, research, and delivery leader interview participants was CDC’s NHSN (Centers for Disease Control and Prevention, 2017b). NHSN collects data on specific HAIs and basic facility-level characteristics from an expanding number of hospitals and other health care settings and has become increasingly used for CMS and other quality reporting as well as for research on HAI-related patient safety improvement.

CDC also has grown its capacity in economic modeling for cost-effective research on the costs and potential savings associated with the adoption of prevention interventions, some of which may accrue to society at large and some specifically to health care systems.

Interview and TEP participants, especially those with PCR expertise, noted that much of CDC’s prevention practices are delivered through primary care, including screening and immunizations. Some CDC research on these prevention practices include primary care settings and providers. As described above, CDC projects also have examined primary care linkages to broader public health and community prevention resources.

Most of CDC’s health outcomes analysis related to HSR and PCR is conducted intramurally. Research on prevention services that include HSR and PCR components is also funded through extramural grants to individual investigators and university centers.

Centers for Medicare and Medicaid Services

CMS provides health coverage to more than 100 million people through Medicare, Medicaid, the Children’s Health Insurance Program, and the Health Insurance Marketplace. CMS seeks to strengthen and modernize the nation’s health care system, and to provide access to high-quality care and improved health at lower costs (U.S. Government, undated).

CMS generates HSR and PCR through the evaluation work it sponsors in support of its business objectives. Federal, research, and state interview participants observed that, although CMS evaluation focuses on the populations and services covered by the agency’s programs (e.g., elderly for Medicare, low income for Medicaid), the size of these programs and the typical rigor of the evaluation have resulted in a considerable amount of HSR and PCR. It was also noted that since these evaluations have a primarily applied purpose to inform policy and decisionmaking for CMS programs, the research tends to be on a shorter time horizon relative to research programs in research-oriented agencies.

CMS’s two main portfolios of HSR and PCR consist of quality measurement in the agency’s CCSQ and demonstrations of payment and delivery models in the CMMI.

Research and other policy-related interview participants reported that CMS has become increasingly involved in quality measurement and improvement with changes in policy and agency programs over the past decade that emphasized these tools and functions. In terms of research, CCSQ funds contractor development of certain quality measures, such as for hospital and facility-based services, although most measures used by CMS are developed outside of the agency (e.g., endorsed measures by the National Quality Forum), including those for primary care. CCSQ additionally conducts intramural research supported by contractors to identify trends or variability in undesirable outcomes on which to focus its improvement and technical assistance programs (e.g., Quality Innovation Network-Quality Improvement Organizations and Hospital Improvement Innovation Networks) or update standards of care for Medicare’s conditions of participation. CCSQ also funds independent evaluations of its quality measurement and improvement programs, such as the National Impact Assessment of the CMS Quality Measures Reports required by law (Centers for Medicare and Medicaid Services, 2018). Last, CCSQ staff work with contractors to provide data on Medicare, Medicaid, and other CMS programs to the research community, such as through its Virtual Research Data Center (Research Data Assistance Center, 2019). These data can be used to conduct further independent evaluations of CMS programs, as well as research on more general HSR and PCR topics.

CMMI was established by the ACA in 2010 with the explicit mandate to implement and evaluate demonstrations of models that test new approaches to paying for and delivering health care with the goal of reducing CMS spending and improving quality of care for CMS beneficiaries (Centers for Medicare and Medicaid Services, undated-a; Government Accountability Office, 2018). Federal, state, and other interview participants, as well as TEP members, noted that CMS, particularly since the ACA, does not fund general research on health care payment reforms, systems, or incentives. All CMMI research activity is tied to the design of demonstrations and evaluations of specific models being tested or under consideration for testing for CMS programs. Evidence used for developing models comes from research sponsored by other agencies or funders, or evaluations of previous CMMI model tests (Government Accountability Office, 2018). Models to be tested are selected through a stakeholder consultation process managed by the agency.

By statute, all CMMI model demonstrations must include formal evaluations, which are conducted by independent contractors and constitute the center’s largest research-related investment. Models include payment incentives and often technical assistance for facilities or providers to implement a new care delivery approach. The primary purpose of the model evaluations is to inform agency actuarial analysis and leadership decisions on whether a model should be expanded within CMS’ payment programs. However, a range of interview participants observed that CMMI evaluations have generated a great deal of evidence on not only whether a model met the agency’s criteria for expansion, but also how and why the model worked, and for which types of providers and beneficiaries, thus contributing much understanding about the models and their implementation. At the same time, some state and other interview participants, as well as TEP members, perceived the CMMI evaluations to have contributed more evidence on effects of new payment systems—an important area—than on the technical assistance components and other levers for promoting implementation and scale-up of delivery innovations.

CMMI to date has launched more than 40 model tests (Kaiser Family Foundation, 2018), including various ACO models to incentivize groups of clinicians, hospitals, and other health care providers to coordinate and improve care for Medicare patients; episode-based payment initiatives for procedures such as hip and knee replacement; and initiatives focused on Medicaid and Children’s Health Insurance Program populations (Centers for Medicare and Medicaid Services, undated-b). CMMI models have also included a number of payment and delivery demonstrations specifically focused on primary care transformation, such as Comprehensive Primary Care Plus, the Transforming Clinical Practice Initiative, and Advanced Primary Care Practice demonstrations for PCMHs in multipayer settings and FQHC safety-net providers. ACO demonstrations also typically include a focus on the role of primary care in coordinating services with other providers.

In addition to intramural research required to design new model tests, CMMI staff conduct a modest amount of analysis on targeted questions, typically with existing CMS secondary data, related to the center’s mission. The center’s dissemination strategy also utilizes multiple communication strategies to inform its main audience, the policy community, of the results of model tests. These include policy companion pieces to the evaluation technical reports that distill key findings, social media postings, as well as publications in the peer-reviewed health policy literature.

Health Resources and Services Administration

HRSA’s mission is to improve health and achieve health equity through access to quality services, a skilled health workforce and innovative programs (Health Resources and Services Administration, 2019). Study participants noted HRSA for its support of services for safety net and other vulnerable populations, as well as health care workforce development. Most of HRSA’s extramural funding provides grants for direct services and service infrastructure that do not include research. However, HRSA also has supported long-established programs of research and evaluation related to its main functional areas, which the agency has more recently expanded in part to inform decisions about costs, interventions, and quality of care for the populations it serves (Dievler and Fisher, 2017).

The agency’s Bureau of Primary Health Care not only provides major service funding for community health centers for underserved populations, it collects extensive information on the health centers through its Uniform Data System and patients through a periodic Health Center Patient Survey. The Bureau makes these data available to the wider research community as well as engages an external research contractor to conduct analyses. The agency also established the Community Health Applied Research Network, a nationwide practice-based network of 17 health centers to conduct patient-centered outcomes research among underserved patient populations. Other HRSA research for specific populations and services include the Maternal and Child Health Bureau’s long-standing program of intramural research on issues such as the organization and delivery of health care and preventive and early intervention services for maternal and child populations; the Office of Rural Health’s funding of extramural Rural Health Research Centers that assess access and disparities of care among rural populations, and the effectiveness of interventions such as telehealth, critical access hospitals, and other service delivery models for rural residents; and the Ryan White HIV/AIDS program, which conducts research on health care disparities, services, and innovative models of care for under- and uninsured individuals served by its funded HIV centers. More broadly, NCHWA serves as a national resource for projections of health care workforce supply and demand, and analysis of the distribution and education of the nation’s health workforce (Health Resources and Services Administration, undated-b). As with other HRSA programs, NCHWA provides extensive data and information for use by the wider research and policy community.

National Institutes of Health

NIH’s mission is to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability (National Institutes of Health, 2017b). Although the vast proportion of NIH’s research portfolio is focused on basic, clinical, and translational research, federal and research interview participants and TEP members noted that NIH Institutes and Centers (ICs) fund a considerable amount of HSR and PCR both intramurally and extramurally (in response to special funding opportunities as well as unsolicited, investigator-initiated grants).

NIH’s portfolios of research in HSR and PCR also play a fundamental role in funding research on the effectiveness and implementation of care practices and interventions typically focused on specific diseases, body systems, or populations, according to the individual missions of the agency’s component ICs.¹ PCR interview and TEP participants reported that NIH has been an important source of funding and sponsor of important studies in the PCR field. They commented that ICs organized to address specific diseases or body systems tend to focus on screening, managing, and coordinating care for those diseases or body systems by primary care providers. ICs organized to address particular populations were noted to also sponsor research related to broader influences on population health, such as the effect of insurance payment and coverage of care.

Federal and research interview participants observed that some ICs within NIH have a stronger emphasis on HSR and PCR than others. They attributed this variability to several reasons, including congressional mandates and other directives, as well as concerns from extramural research communities, such as to increase the adoption of evidence-based clinical interventions by practitioners. For example, when NIMH, NIDA, and NIAAA were relocated back within NIH in the 1990s, Congress had mandated that the agencies commit at least 12 percent of their funding for HSR (Norquist and Magruder, 1998). While there is no longer a mandate, these institutes continue to fund HSR, and NIMH was noted as having an especially strong HSR emphasis, including a program on primary care and mental health. Similarly, the NCI’s founding legislation in the 1970s assigned the responsibility for lowering the burden of cancer, which federal interview participants noted to have oriented the institute at an early stage toward research on the systems of care that affect cancer treatment and outcomes in communities. The NHLBI’s emphasis on HSR was partially attributed by a federal interview participant to the influential Framingham study, which helped orient the Institute toward broader sets of community risk factors for heart disease. The NIDDK was noted by federal interview participants as focusing on a number of HSR- and PCR-related topics, such as HIT interventions in primary care settings, workforce issues in training of community health workers, health care partnering with community organizations, and even aligning care delivery with reimbursement for intensive behavioral interventions.

Interview participants also observed that Institutes focused on specific populations, including the NIA, NICHD, and NIMHD likewise sponsor research on HSR and PCR questions. Federal and research interview participants noted that NIA and NICHD have both funded research on issues such as coordination of care and the effect of insurance payment and coverage on care, and NIMHD has funded research on disparities in health care utilization and access and the use of nurse practitioners to reduce disparities in care.

TEP and interview participants identified two other ICs that have sponsored HSR and PCR. NINR has supported research on team-based care. NLM has funded projects on data creation, use, and dissemination, as well as health informatics applicable to health services. NCATS funds Clinical and Translational Science Awards to medical institutions across the country. Research interview participants considered much of this work to focus on earlier stages of translation from biomedical science to clinical interventions, although they perceived this to vary as researchers in some Clinical and Translational Science Awards have used the community and patient engagement cores of these centers for later-stage translation of clinical interventions into health care practice.

Last, federal interview participants noted that certain trans-NIH initiatives funded through the agency’s Common Fund have provided opportunities for its research to more broadly engage health care delivery systems. The Common Funds’ Health Economics program funded research from 2001 to 2017 on the effect of economic factors, such as financial incentives, insurance, and drug pricing, on health care and health (National Institutes of Health, 2017b). NIH issued guidance in 2015 on health economics research funded by the agency, to clarify that research on economic models and methods can be used to support NIH’s mission. NIH supports health economics research in which health outcomes and health-related behaviors are the primary focus, and the connection between the subjects of the study and improved understanding of health is clear and explicit, and economic factors should not be used as primary outcomes of NIH-sponsored research. Although the purpose of the notice was to prevent drift in research away from NIH’s mission on understanding health-related behavior, utilization, and outcomes (National Institutes of Health, 2017b), some HSR TEP and research interview participants considered the guidance to nonetheless limit opportunities for funding of economic analyses of health care systems. An initiative funded primarily through the Common Fund since 2012 has been the Health Care System Research Collaboratory, which supports nine large-scale, pragmatic clinical trials that involve partnerships with health care delivery organizations. The program aims to enhance the capacity to conduct research with health care systems and strengthen the relevance of research results to health practice. ICs now also directly support additional pragmatic clinical trials in the Collaboratory (National Institutes of Health, 2017b).

¹ NIH also contains Institutes, Centers, and Offices that focus on professions (NINR), treatment modalities (NCCIH), and research areas (Office of Behavioral and Social Science Research).

Veterans Health Administration

The mission of the VHA within the VA is to provide accessible, high-quality, cost-effective care for military veterans (U.S. Department of Veterans Affairs, 2016). It operates the country’s largest integrated health care system, serving 9 million military veterans through 170 medical centers and more than 1,000 outpatient sites (U.S. Department of Veterans Affairs, 2019b). The objectives of HSR funded by the VHA are to conduct research that will help improve the health care and health of veterans, as well as advance the field of HSR based on the unique capabilities of the VHA system.

The VHA’s HSR portfolio is generated through three programs. The VA Health Services Research and Development program awards investigator-initiated grants to researchers within the VHA system to identify and evaluate innovative strategies to improve veterans’ care. The Quality Enhancement Research Initiative supports and evaluates the use of quality improvement methods to implement evidence-based practices into routine care for veterans (U.S. Department of Veterans Affairs, 2018b). The VHA’s Centers of Innovation embed VHA health services researchers with clinical and operational partners to ensure that research has the greatest possible impact on VHA policies, health care practices, and health outcomes for veterans (U.S. Department of Veterans Affairs, 2018a).

Federal and research stakeholders described the VHA’s HSR portfolio as broad and varied and focused on the particular challenges for veterans’ health and the priorities of the VHA system. For example, VHA’s HSR portfolios address improving the quality and safety of specific services for pain, including opioids and use of complementary and integrative therapies; suicide prevention, co-occurring disorders, and other mental and behavioral health problems; trauma and traumatic brain injury; health care for women, the fastest growing segment of the veteran population; aging, due to the demographics of previous generations of veterans; and management of complex, high-risk patients, based on the greater prevalence of multimorbidity in the veteran population. Given specific challenges of the VHA system, the VHA research portfolio has also focused on broader HSR issues, such as defining and improving access to care, use of telehealth for a range of services, and rural health care, which overlaps with access and telehealth. Coordination of care with other health delivery systems has become a research interest with the recent passage of the Mission Act in 2018 that offers veterans greater options to receive care outside of the VHA (U.S. Department of Veterans Affairs, 2019a).

Primary care is a large component of the VHA system, and PCR likewise comprises a large component of the VHA research portfolio. In addition to access, telehealth, and management of multimorbidities in primary care, other major PCR topics have included integrated primary and behavioral health care, and evaluation of a national rollout of the VHA’s medical home model (PACT) across the system.

One research interview participant mentioned that concerns are occasionally raised about the generalizability of some HSR and PCR results from the VHA due to its unique nature as a federally operated, integrated health system. However, other research and delivery leader interview participants reported that many HSR and PCR findings produced by the VHA have been shown to be applicable and useful in other health care settings, for example, use of VHA research on trauma-informed care and telehealth by safety-net community health centers.

Federal and research stakeholders additionally pointed to the VHA’s advantages in HSR as the largest and longest-operating nationally integrated health system, including development of system-wide, standardized quality, and safety measures, and application of 25 years of comprehensive, longitudinal EHR data to perform unique types of HSR analyses, as well as to understand the use of EHR data systems to measure and improve care. Other methods areas noted as strengths of the VHA by federal and research interview participants included the Quality Enhancement Research Initiative’s emphasis on implementation science and translation of research findings into practice, and the Centers of Innovation emphasis on best practices for embedded research. 

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