AHRQ leader: Tough decisions needed to improve U.S. health care system

AHRQ director says agency wants physician input on grappling with access, costs, burnout.

Robert Otto Valdez, PhD, MHSA, was appointed director of the federal Agency for Healthcare Research and Quality (AHRQ) in February 2022. Previously he served in a number of government and academic posts, including stints at the federal Department of Health and Human Services and as special senior adviser to the White House Initiative on Educational Excellence for Hispanic Americans. Nearing the end of the first full quarter in his tenure, Valdez spoke with Medical Economics to discuss the status of the American health care system and AHRQ’s role in finding solutions to current difficulties. The interview was conducted via Zoom and the following transcript has been edited for length and clarity.

Medical Economics (ME):You have a long career in many facets of healthcare policy, finance and practice, and joined AHRQ in February this year. What should physicians know about what the agency does?

Robert Otto Valdez: Well, AHRQ was set up really with the mission of improving health care in the United States. Unfortunately, the vast majority of the public know very little about AHRQ and its work. The vast majority of our work is based on health services, research, practice improvement, and the monitoring of the function of the healthcare system, through a set of primary data systems and datasets that help policymakers at the federal and state levels make decisions that affect the regimes in which health care is practiced at the various states and local communities. All healthcare is local. And so it's extremely important for us to understand what's going on across the nation. It's extremely difficult for people to actually understand, what real knowledge do we have? What real evidence do we have for improving healthcare? And so much of the work of AHRQ, and its contributions to other agencies within the department and into the field, is to examine all of these publications and studies and whittle that down to what we actually can generalize and have confidence in as evidence for practice.

ME: Earlier this month, AHRQ was a participant in the AcademyHealth Annual Research Meeting. In a recent blog entry, you talked about the conference and disseminating and implementing findings, “to improve our tattered health care system.” What would you like to see improved in the health care system? What needs to be repaired?

Valdez: Oh, what doesn’t need to be repaired? The pandemic really exposed longstanding problems in our health care system: access barriers, uncontrolled prices and costs, unacceptable quality, widespread racial and ethnic disparities and inequities in the way resources are distributed across the country and locally. As I said, all healthcare is local. And there are great disparities and inequities from region to region and even within states, location from location. The costs are really out of control. Our national spending really is projected to eat up 1/5 of the entire economy by 2026. That means we have to give up many, many other things in our society that we think are important. We pit our health care against educating our children when we do this kind of expenditure of our resources. So we’ve got to make some really tough decisions about what we can do.

ME: How are all these factors these affecting patients and clinicians?

Valdez: Access is extraordinarily uneven from region to region, from location to location. And they reflect state policy regimes that dictate how health care can be practiced, and how services can be provided from one state to another, even when you're right next to each other. Safety and quality, as I said, are dangerously poor. The pandemic has only made things worse, that over the last couple of years, all of the gains that we made in the previous five years in health care safety or safety issues, have largely been lost. Central line infections, for example, which had been reduced by 32%, have increased by 28% in the last 2 1/2 years. So, basically, we've wiped out all that we've done in the past. And it's understandable because a lot of the safety issues are the result of our overburdened workforce. And the need for our organizations to regain a culture that that is focused on safety, and quality. We've also seen our healthcare investments misdirected. We have created investments in IT services that actually have contributed to this overburdening of our workforce, and as a result has contributed to the burnout that we're seeing all across the country. That burnout is really one of the major issues.

ME: Just last month, the U.S. surgeon general issued an advisory on health worker burnout. How widespread is that problem?

Valdez: I talked to my colleagues who are still running health systems, I've had the privilege of serving as a faculty member to train health executives run health care organizations around the country. And when I talked to my colleagues and my former students and I asked them, what's the number one problem that you're trying to deal with today? Their response is always personnel shortages, dealing with the burnout. And of course, financial challenges are also taking their attention because during the pandemic, we've lost a lot of revenue because lots of patients were unable to pursue their regular services because we were dealing with the surge of pandemic demands. That's also led into this whole issue of patient safety and concern. But everybody's really concerned about the employee burnout situation, which seems to be running rampant across the country, and is really causing a lot of the reason I say tattered.

Fundamentally, we're a service industry. And we can only serve as many people as we have people to serve. And we can only do it as well as our healthcare workforce are maintaining their wellbeing. So I think it's extremely important that when we think about not only patient safety, that we also think about the safety of our workforce, and the wellbeing of our workforce, because it's that dyad, both sides of that dyad have to work well, have to be functioning, for care to reach its maximum optimal level.

ME: When you were appointed earlier this year, Health and Human Services Secretary Xavier Becerra commented on AHRQ’s critical work to improve primary care. How can the agency do that?

Valdez: Well, what most people don't know is that our authorities from Congress from 1999 was to improve health care in America, on health care in its broadest sense, safety, quality, access, even costs. And that's a daunting task. The Affordable Care Act turned around and said, not only do you need to do that, but it needed to be recognized that primary care, and improving the primary care system in our country, has got to be the backbone of building a high-quality health care delivery system. And so, since that time, we have been focused both on primary care research, but also trying to figure out ways to help primary care become better in our country. And we've gone about that by a number of pilot projects, which are now ready to be scaled up and to go national. So one of the projects that we're looking at, is similar to the agricultural extension program that the Department of Agriculture operates, and to really create a primary care extension program that supports small and medium-sized practices, as well as healthcare delivery systems that operate larger primary care arrangements, so that we can more directly assist those practitioners acquire the new knowledge that's gained by the kind of evidence-based programs and the evidence generation that we do here at the agency, and have a systematic way in which that evidence can be brought into the clinic and into the practice of primary care. That's one of several ideas that we're working on right now, to gain federal funding in our next appropriations actually accomplished. Because one of the things that's clear is that we have that opportunity to do these kinds of fundamental changes in our healthcare system, largely because of the stresses and strains the pandemic has put on our local healthcare delivery systems and our primary care.

ME: What did I not ask about that primary care physicians should know, or what would you like to say to primary care physicians?

Valdez: We pay so much more for our health care, and we get not the highest quality of care when you compare us to other things that are going on around the world. And so I think we increasingly need to refocus on what it means to provide high quality care. The settings of care have changed dramatically over the course of even the last decade. I like to use the example of hip replacements. Hip replacements used to take place in the hospital, and people would have stays in the hospital that were costly and relatively long. Today, you can have a hip replacement in an outpatient setting, and begin to start your efforts to be ambulatory within the next couple of hours. And, increasingly, those kinds of procedural activities are taking place in other settings, and increasingly in outpatient settings, and even in primary care settings. And so increasingly, we need to ask ourselves: What does high quality mean, as we move from different settings of care? Different kinds of procedures, different kinds of practices, are now taking place in long term care settings. They're taking place as I suggested at home with the example I gave you earlier. So AHRQ is busy trying to understand and try to get ahead of where we're going with the future of healthcare, particularly a future of primary care. What does that look like? What is that going to look like when we're doing these video calls and I happened to be on Mars? Or circling around a planet somewhere? What is the future of healthcare in 50 years? We're trying to get a handle on that now because if we don't, then we're going to be completely chasing the problems the way we chased them now. They appear and then we try to figure out a problem resolution well beyond after it's reared its ugly head. So we're trying to think ahead. We look forward to suggestions and ideas from your audience for where we ought to be heading.