by Melford Henderson, Brent Sandmeyer, and Amy Taylor

With its recent announcement of funding opportunities and research emphasis, the Agency for Healthcare Research and Quality has signaled to the research community its desire to intensify research funding on areas of interest to ASHE membership. AHRQ is funding research with grants not to exceed $250,000 per year and lasting up to 5 years, with applications for smaller grants also being encouraged. Submission dates occur throughout the year: R01 (large grant) – Feb. 5, June 5, Oct. 5 (see at grants.nih.gov/grants/guide/pa-files/PA-14-291.html); and R03 (small grant) – Feb. 16, June 16, Oct. 16 (see grants.nih.gov/grants/guide/pa-files/PAR-10-168.html).

Of particular interest to ASHE readers will likely be AHRQ’s new priorities 3 and 4. Excerpting from AHRQ’s Funding Opportunities Announcement Guidance these two priorities are described as:

Priority #3. Increase Accessibility to Health Care

Access to health insurance coverage remains a critical public policy issue. Health insurance helps people get timely access to medical care and protects them against the risk of expensive and unanticipated medical events. Accurate and informed public policy analysis and policy design require precise estimates of the size and composition of the insured and uninsured populations, as well as information on how demographic characteristics, economic factors and health insurance subsidies affect health plan eligibility, decisions to enroll in health insurance plans and trends in health care expenditures and affordability. Evaluation of the equity and stability of health insurance coverage requires information on the ease with which health insurance transitions are made and how satisfied individuals are with their plans and issues of affordability.

Understanding how policies will affect the evolution of health insurance markets and the health insurance landscape continues to be important issues for study. For example, innovations in health insurance markets, such as the newly created Health Insurance Marketplaces and minimum standards for plans, are important developments to be analyzed. Issues of particular interest include: the relationship between changing health insurance markets and structural changes in the American workplace, especially in light of recent changes in the economy; analyses to assist in the implementation of and improve our understanding of the impact of health care reform on coverage, access and affordability; and the effects of changes in health insurance benefits on consumers’ financial burdens and access to care

AHRQ is engaged in efforts to provide evidence on the effects of health insurance coverage expansions on the health and financial security of the uninsured, on labor markets, on health care providers, particularly those in the safety net, and on employer and employee decisions with respect to employer-sponsored insurance. New evidence generated from this initiative will assist federal and state policy makers and private payers with assessments to help them make key decisions in these areas. Attention will be given to improving our understanding of the causes and consequences of lack of insurance, and the effects of health insurance expansions on access to care, utilization of health care, health care spending, affordability and health outcomes.

AHRQ encourages grant applications that propose research that focuses on the topics of health insurance coverage, access to care and health care costs with specific emphasis in the following areas:

• What is the impact of Medicaid and Marketplace coverage expansions on enrollment, access, health care use and expenditures, healthcare disparities, affordability and outcomes?
• What methods are most effective in assisting eligible people to understand coverage options in the Marketplace and to enroll in Medicaid?
• How are the decisions that employers and employees make about employer-sponsored coverage (for both large and small employers), such as those related to plan characteristics, offer and take-up rates, affected by the ACA?
• To what extent does churning of coverage – between Medicaid and the Marketplace, and between being insured and uninsured – create challenges for continuity of care, and what sorts of community-level responses have been most successful in mitigating those challenges?
• How has the ACA affected the overall structure of the insurance market, including the availability of and enrollment in different types of plans and the mix of employment related versus individual coverage?
• What effect has the ACA had on changes in cost-sharing arrangements and the composition of provider networks, and what effects, if any, have these changes had on access to care, patient outcomes, and health care expenditures?
• How do reimbursement and financing mechanisms affect health care expenditures?
• How do tax incentives affect coverage decisions and the level and distribution of health care expenditures and financial burdens?
• What reimbursement and financing mechanisms are effective in controlling health care costs without having adverse effects on quality and access?
• How will changes in the demographics of the population affect health care access, coverage decisions and health care expenditures?

Priority #4. Improve Health Care Affordability, Efficiency, and Cost Transparency

Producing evidence that can be used to increase the affordability, efficiency and cost transparency of health care for all Americans is a major AHRQ priority. Potential research areas and questions include but are not limited to the following:

• Reducing Cost Growth: In order to make health care more affordable, we must understand the drivers of those costs and their growth, as well as the relationship between cost and quality.
• What micro and macro factors have led to the overall changes in national health care cost growth? What is the impact of consolidation and other market changes on the cost and price of health care in particular markets? What is the impact on health care performance, disparities, and safety net facilities?
• How well have Integrated Care Models and their associated reimbursement models (e.g. bundled payments) actually integrated care and reduced costs, readmissions, and post-acute care utilization?
• What is the impact of health IT innovation and health information exchanges on costs?
• What is the extent and cause of geographical variation in costs, quality and utilization?
• How can we improve methods of measuring the cost and outcome of new technologies, procedures, or drugs? What advances can be made in outcome and cost modeling? How can we improve methods of measuring overutilization? How can we best assess the impact of the Choosing Wisely campaign or other provider-based strategies to reduce overutilization? How can we best assess the impact of new malpractice tort reforms on costs and defensive medicine?
• Comparing Performance of Systems and Providers: AHRQ is interested in funding research that will allow comparison of delivery system and provider performance by health care stakeholders such as consumers, providers, payers, insurers, and policymakers.
• How do different types of delivery systems compare on performance? Under what circumstances, and with what success, do systems include public health providers or non-medical service providers?
• What structural, functional (including clinical), financial, and operational features are associated with higher performance? What are the factors that most strongly differentiate higher performing from lower performing systems?
• What metrics best measure the performance between and within systems for different audiences such as consumers, payers, and providers, and how can these metrics be improved?
• Incentives for Improving Performance: The Affordable Care Act, Federal and state regulations, and public and private payers have provided a variety of financial and nonfinancial incentives to improve the performance of health care providers and systems.
• How do different financial incentives affect health care market structures and system and provider performance? What impact do different types of incentive structures have on disparities in care? How are behavioral economic approaches such as “nudges” or choice architecture being used to affect provider or consumer decisionmaking, and with what effect?
• What non-financial incentives, such as price transparency, public performance reporting for consumers, private performance feedback reports to physicians, and professional norms, work to improve system performance, and under what circumstances?
• When and how do consumer financial incentives, such as provider tiering, reference pricing, and high-deductible health plans affect consumer decisionmaking and the quality or affordability of care?
• Interventions to Improve Performance: While alignment with external incentives is very important, it is the provider or system that implements interventions to increase efficiency, while maintaining or improving affordability, quality, equity, and access, and reducing disparities. Interventions may be localized to a lone provider or system, but may also be undertaken on a regional or national scale such as through quality collaboratives or specialty societies.
• What interventions have been most successful in improving performance and why? What conditions are necessary for implementing these interventions? Are there particular factors to consider when designing interventions involving safety net providers?
• How readily can successful interventions be adapted and implemented by systems and providers operating under different conditions?