NIH research: big money, small returns.

This column often describes how partisan divisions in Washington sabotage efforts to tackle fundamental problems in long-term care policy and healthcare for the elderly. There is, however, one healthcare policy on which both parties are in complete agreement: more money for the National Institutes of Health (NIH), the primary medical and healthcare research programs of the federal government.

When Bill Clinton became President, the annual NIH budget reached the milestone level of $10 billion. In the last year of his administration, President Clinton and the Republican majority in Congress approved an NIH budget of $20.4 billion, and negotiated a multiyear plan to grow the budget even more.

George W. Bush, as a presidential candidate, promised to complete the five-year plan to expand the NIH's funding. He specifically suggested that a primary focus of the NIH should be to spend its budget on a cure for Alzheimer's and other chronic diseases. "As President, I will fund and lead a medical moon shot to reach far beyond what seems possible today," he said.

President Bush upheld his promise: He has requested $27 billion for the NIH next year, a 32% increase over the NIH budget when he took office. The President's proposal would allow the NIH to fund more than 10,500 new and competing research grants. His Democratic competitors, however, will not let this generosity go unchallenged. For example, Sen. Bob Graham (D-Fla.) promises still more increases for the NIH research budget, if he is successful in his presidential bid. Another Oval Office contender, Congressman Richard Gephardt (D-Mo.), suggests tripling the NIH budget. Sen. Joe Lieberman (D-Conn.) has proposed creation of an American Center for Cures, funded at $150 billion over 10 years, to cooperate with the NIH in evaluating and implementing promising new medical treatments for common chronic diseases. In fact, one of the few politicians who explicitly doesn't want to increase the federal medical research budget is former Vermont governor Howard Dean--interestingly enough, the only clinician in the presidential sweepstakes.

Long-term care administrators and staff may wonder when they will see the benefits from this enormous increase in taxpayer-funded medical research. After all, the $7 billion per year increase in the NIH budget endorsed by President Bush could pay the care costs of more than 2,000 nursing home residents per state. In particular, will the billions of dollars in new money for the NIH translate into improved care and cost-effective treatment for Alzheimer's and other chronic age-related conditions?

There's no doubt that NIH research already is helping with some of the most difficult chronic problems of aging. The NIH National Institute on Aging (NIA), for example, provides support to increasingly successful studies on how to stop the spread of Alzheimer's (see NH News Notes, p. 10, for an NIA-cofunded study on a possible tripling of Alzheimer's cases in 50 years), and other NIH Institutes are sponsoring research on arthritis and progressive loss of hearing and vision. Part of the reason, though, that these advances have not yet transformed into nursing home practice is the lengthy process needed for conducting human clinical trials testing treatment safety.

It is also worth noting that much of the most useful research on the chronic diseases of aging was accomplished during the 1990s, when the NIH budget was much smaller. Doubling or tripling the NIH budget will not necessarily produce two or three times as much information useful to long-term care. It's possible that larger NIH budgets will not make much of a difference at all in preventing or treating the disabling conditions of old age.

Several aspects of NIH research contribute to the diminishing returns of budget increases:

There are a limited number of qualified experts who are able and willing to conduct original research on the conditions found in long-term care. Medical research is not an industry in which productive people can be quickly hired and put to work when new money becomes available. It takes years to train lead scientists and to place them in positions in which they can develop proposals for new research projects to be funded by NIH.

More grant money means that lower priority research is funded. In any given year, the NIH reviews and evaluates thousands of research proposals. In the mid-1990s, only the most highly rated proposals were funded--roughly 15 to 20% of the total submitted. Today, the NIH states that it can fund approximately one in three of the research grant applications received. In other words, the most promising research has always been funded, even when the NIH budget was much lower, and the larger budget allows less promising studies to receive federal funds.

Geriatric research is shrinking as a component of the overall NIH budget. Two years ago, Stephen Bartels, then president of the American Association for Geriatric Psychiatry, testified to Congress that spending on studies relevant to aging had not kept pace with the dramatic increase in NIH funding. While President Bush has proposed more than a 12% increase in the total NIH budget for next year, NIA will receive an increase of only one-tenth of one percent--not even enough to keep up with inflation.

The methods that the Institutes use to select grantees also contribute to the limited benefit that long-term care derives from the NIH budget. The peer review panels that rate research proposals are heavily weighted toward college professors and industry researchers, who are familiar with laboratory methods and formal clinical trials; NIH staff familiarly calls them "rat-in-the-pocket types" because of their comfort with research based on animal models. The panels tend to award the most rating points to proposed studies that resemble their own research techniques. This means that practical approaches to improving nursing home resident outcomes tend to fall lower on the research priority list.

During recent months, state government budget problems have created a further obstacle to NIH support for research that is useful to nursing homes and long-term care. The faculties of state universities and colleges often are important sources of applications for research grants relating to long-term care. Unfortunately, these faculty members often have been the first to go when states move to cut "nonessential" personnel to balance their budgets. It's ironic, therefore, that the federal government's penny-pinching on revenue sharing with the states has made it more difficult to find suitable candidates for NIH grant support.

In the final analysis, when politicians of both parties tell audiences that their healthcare platform features more money for the NIH, the members of the long-term care community seeking definable returns have a choice: They can start looking for underemployed academics who may be willing to write grant applications that use long-term care facilities as a testing ground for innovative care practices, or they can tell Washington that there are many more ways than basic research to spend money sufficient to make a real difference in nursing home quality of care.

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