The following is the featured luncheon address presented by Dr. Hanft on April 12 at the FCER's 1991 International Conference on Spinal Manipulation. Dr. Hanft's address includes some preliminary findings from the CHPG study. FCER will complete the study report in the fall of 1991. Introduction Before discussing the issue of chiropractic positioning for federal funding, I would like to make a few generic comments.
- Freestanding single purpose professional schools have an inherent disadvantage in seeking federal funding, particularly research funding, in contrast to university-based components.
- Osteopathic medicine, until the 1960s, received little or no federal funding. Capacity building was undertaken by some of the schools, particularly state university schools with growing competitive success in the 1980s.
- Podiatric medicine and optometry face the same issues as the chiropractic profession. The majority of institutions are single purpose professional schools without adequate resources/capacity to successfully compete for scarce federal funding.
- Federal funding for health professional education programs has declined substantially since the mid 1970s. At the same time there has been an increase in the number of schools in all of the professions, with the exception of dentistry competing for a smaller pool of funds.
- Federal funding for research has grown slowly at the same time that the pool of researchers competing for funds has grown.
Federal Funding Trends
- The new budget process severely limits the expansion of funding in health care for the following reasons: The major part of the health budget is the entitlement program of Medicare and Medicaid. The remainder of the health programs are subject to the tight budget ceiling for all domestic programs. That means if an increase is sought for education in the health professions, an offsetting reduction must be made. Clearly, interest group politics are of different magnitudes when resources are shifted rather than increased.
- In the last decade the federal government has increasingly targeted programs to meet high priority objectives. In the health professions these are primary care and minority education. In biomedical research, AIDS, the human genome project, cancer, heart disease, and substance abuse are the priorities.
- General institutional support has declined except for special programs for historically black colleges and colleges with large minority student populations.
- The one bright area is the increase in funding for effectiveness and outcomes research. Yet these funds are miniscule compared to the National Institute of Health (NIH) or the ADAMHA research funds.
The Peer Review and Advisory Council Process
Research review at the federal level is complex and has several stages. There are two critical components: the priorities recommended by the advisory councils; and the review by the peer review groups for scientific merit and capacity.
The advisory councils are composed of scientists, clinicians and lay members. They are appointed by the secretary with recommendations from the federal agency. Advisory councils are selected to assure geographic dispersion, representatives of women and minorities, and scientific expertise. These councils recommend priorities for research in each major area such as infectious disease, etc.
The peer review groups perform the actual grants review based on the criteria discussed later. There is an inherent bias in the process that favors established researchers and research teams over newly emerging researchers.
This has been an area of criticism that has been debated for years with no satisfactory solution found. For short periods of time the government has had some special programs, mainly for minority colleges to help them develop research capacity to compete in the standard peer review process.
Approximately 80-85 percent of the grants are approved in the peer review process. The review is available to the researchers. The approved grants are scored for merit and then the priorities come into play. A lower scored grant in a higher priority area can be funded while a higher scored grant in a lower priority might not be.
In reviewing applications for research support, the federal government has established criteria for review.
- Scientific merit and methodology of the proposal.
- Credentials and the capacity of the researcher and/or the research team, including prior research accomplishments.
- Capacity of the institution to support the research project in terms of space, support staff, equipment, animal facilities where appropriate, institutional review board, etc.
- Priority ranking of the research subject.
In reviewing data from the chiropractic colleges and the site visit reports, a number of issues have emerged relating to research capacity at the schools. These issues were at one time the same for all osteopathic colleges and for some still are. They are similar to the issues in podiatric medicine and optometry.
The first issue is the composition of faculty. While there has been a growth of doctoral/Ph.D. level faculty in the basic sciences, they are not research faculty. Salary levels are non-competitive for Ph.D. researchers. Teaching loads are very heavy. In addition, faculty with certain critical skills and/or research training are scarce. Post-doctoral fellowships are virtually de rigueur today to compete in the research world. In addition, certain fields need to be represented as support for research, including biostatistics, epidemiology, research methodology.
In terms of clinical scientists, most clinical researchers today have degrees in their profession and a research doctoral degree. There appear to be few or no D.C./Ph.D.s.
The following are the types of actions that the newer medical schools and some of the osteopathic colleges have taken and continue to take to develop the faculty base for research.
- Recruited experienced research faculty, and potential research faculty.
- Provided seed money for the preliminary development of research protocols.
- Encouraged faculty to take subsidized leave for research experience at NIH or university labs.
- Sought collaborative research with known researchers at other institutions.
- Paid competitive salaries for faculty researchers.
- Allocated non-teaching time to promising researchers.
Institutional capacity is another aspect that requires attention. Like research faculty development, the process is a long, slow one.
Successful research schools generally have the following institutional base.
-- A research grants office that provides the following functions:
- Clearinghouse of sources of public/private research resources, including grant solicitations, RFPS etc.
- Repository of research grant regulations and requirements such as human subject experimentation, etc.
- Provide technical assistance in preparation of research proposals.
- Operate institutional internal grant review processes.
- Have formalized grant administration functions.
- IRB function.
Institutions that develop research capacity frequently must front end finance.
- Laboratory space.
- Purchase necessary state-of-the-art equipment.
- Depending on the type of research, invest in animal facilities.
Clearly a university base is an advantage allowing for economies of scale and multidisciplinary faculty that can be drawn on across departments and schools and the existing grants and contracts infrastructure.
Clinical facilities in the health sciences are also a critical component for research, to provide the patient base for clinical trials and efficacy studies. Chiropractic schools, by and large, have a limited patient base.
Health services' research generally requires less in the way of physical facilities, such as labs, but requires a different mix of faculty discipline such as economists, medical anthropologists, sociologists, as well as health professionals. Computer capacity and modeling capability are frequently required.
From the perspective of the chiropractic profession, the wise course to follow might be to start by combining resources into one or two research consortia that would begin to develop the resources required in faculty facilities and support staff. The profession should also consider the newly funded areas of outcomes and effectiveness research and the potential collaborative linkages with existing centers, many of which are not medical school-based.
Some efforts have already been made by researchers. These should be encouraged. Of great importance for future development is faculty recruitment and development, appropriate salary levels and lighter teaching loads.
Let me talk about faculty salaries for a moment. Salaries at the chiropractic colleges are very low comparatively. The competition for experienced biomedical researchers is keen. Without infusion of funds to offer competitive salaries, it is unlikely that the colleges will be able to recruit and retain skilled research faculties.
Teaching loads are also very heavy, allowing little time for scholarly activity and the development of research hypotheses and protocols.
Health Professions Education Programs
Federal investment in education for the health professions has declined substantially over the last 15 years. There is no general institutional support. What remains are targeted programs, primarily for the training of primary care in medicine, osteopathy, nursing, and podiatry, and to encourage minorities in the health professions. There is a small grant program for curriculum reform. Competition is intense. Chiropractic does not meet certain basic defined criteria for primary care or underserved/shortage areas.
The majority of funding for education in the health professions, except in medicine and osteopathy, comes from state appropriations and tuition, not from federal programs, except the indirect funding through research and patient care. All fields, except podiatry and chiropractic, have some state university relationships. The fields most dependent on tuition are podiatry, optometry, and chiropractic.
To develop research and education capacity requires time, patience, and a strategic plan. The chiropractic field faces the same problems in developing this capacity as do podiatry, optometry, and new private schools in any field, and to some extent, the health professions' minority schools. These latter schools within the last five years have successfully competed in research by forming a consortia of researchers from multiple schools to provide a critical mass, and by collaborating with major research institutions. Chiropractic has begun a similar process, which in the long run, with the expansion of skilled researchers, will develop competitive capacity.
To further enhance chiropractic capability, efforts should be made to recruit a cadre of faculty who have completed postdoctoral fellowships and to provide them with research time and encourage continued collaboration with their mentors.
Ruth Hanft, Ph.D.
George Washington University
Dr. Hanft is a research professor at George Washington University in the Department of Health Services Administration and program director for the Robert Wood Johnson Foundation, Local Initiative Funding Partners' Program. Dr. Hanft has served as deputy assistant secretary for Health Research, Statistics, and Technology in the Department of Health and Human Services; and deputy assistant secretary for Health Policy Research and Statistics, heading the Office of Program Development and Planning for the U.S. Public Health Services.
Dr. Hanft received a Ph.D. from George Washington University and an M.A. in political science from Hunter College. She has published extensively in professional journals and has edited and written a number of books on health care.