Research and Service Programs in the PHS: Challenges in Organization

Committee on Co-Administration of Service and Research Programs of the National Institutes of Health, the Alcohol, Drug Abuse, and Mental Health Administration, and Related Agencies

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C. 1991



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Research and Service Programs in the PHS: Challenges in Organization Research and Service Programs in the PHS: Challenges in Organization Committee on Co-Administration of Service and Research Programs of the National Institutes of Health, the Alcohol, Drug Abuse, and Mental Health Administration, and Related Agencies INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1991

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Research and Service Programs in the PHS: Challenges in Organization National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal government, and its own initiative in identifying issues of medical care, research, and education. Support for this project was provided by the Department of Health and Human Services (contract no. 282-90-0014). Library of Congress Catalog Card No. 91-66407 International Standard Book Number 0-309-04581-9 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 S444 Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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Research and Service Programs in the PHS: Challenges in Organization COMMITTEE ON CO-ADMINISTRATION OF SERVICE AND RESEARCH PROGRAMS OF THE NATIONAL INSTITUTES OF HEALTH, THE ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION, AND RELATED AGENCIES STEVEN BEERING (Chair), * President, Purdue University, West Lafayette, Indiana DANIEL AZARNOFF, * President, D.L. Azarnoff Associates, Inc., San Francisco, California JACK BARCHAS, * Associate Dean for Neuroscience, UCLA School of Medicine, Los Angeles, California ROBERT BINSTOCK, Professor of Aging, Health, and Society, School of Medicine, Case Western Reserve University, Cleveland, Ohio GERT BRIEGER, * Professor and Director, Institute of the History of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland WILLIAM DEWEY, Professor of Pharmacology, Assistant Provost, and Dean of the Graduate School, Virginia Commonwealth University, Richmond WILLIAM FULLERTON, * Consultant, Health Policy Alternatives, Inc., Crystal River, Florida PATRICIA GOLDMAN-RAKIC, Professor of Neuroscience, Yale University School of Medicine, New Haven, Connecticut JAMES HAUGHTON, * Medical Director, King-Drew Medical Center, Los Angeles, California WILLA HSUEH, Chief, Division of Diabetes, Hypertension, and Nutrition, University of Southern California Medical Center, Los Angeles, California CHARLES KIESLER, * Professor of Psychology and Provost, Vanderbilt University, Nashville, Tennessee ROBERT MICHELS, Dean, Cornell University Medical Center, New York, New York * Member, Institute of Medicine

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Research and Service Programs in the PHS: Challenges in Organization MARK PAULY, * Professor of Public Management and Economics and Executive Director, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia DONALD STEINWACHS, Professor of Health Policy and Management and Director, Health Services Research and Development Center, Johns Hopkins University, Baltimore, Maryland INSTITUTE OF MEDICINE STAFF RUTH ELLEN BULGER, Director, Division of Health Sciences Policy MADY CHALK, Study Director KATHLEEN STRATTON, Associate Study Director CATHARINE CHETNEY, Research Assistant RITA GIBSON, Administrative Assistant BEVERLY PROCTOR, Project Secretary

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Research and Service Programs in the PHS: Challenges in Organization Preface Over the past 25 years, questions have often been raised about the role of the Public Health Service (PHS) in funding, planning, and administering research and services development and demonstration programs, and about how the PHS is organized to carry out its research and services development functions. This study was motivated by a number of specific concerns raised in the past 5 years by constituency groups; by members of Congress; by the leadership of the National Institutes of Health (NIH) and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA); by grantees of the two agencies; and by analysts of federal research and development activities. For example: Constituency groups (grantees, advocacy groups, professional associations, etc.) have raised questions about priorities and levels of funding for either research or service activities, and about how research and service development and demonstration programs fare under a single administration such as ADAMHA. The leadership of NIH and ADAMHA and professional groups have questioned whether a single director or administrator can effectively manage an agency responsible for both research and service activities. Members of Congress have expressed concern about reductions in the services components of ADAMHA (reductions that seem to reflect a change in ADAMHA's congressionally authorized mission) and about the need for increased attention by NIH to the transfer of the results of basic research into clinical practice. The Committee on Co-Administration of Service and Research Programs was asked to evaluate and discuss the advantages and

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Research and Service Programs in the PHS: Challenges in Organization disadvantages of administering service programs in conjunction with administering research and research-related activities in the PHS. The committee consisted of 14 individuals appointed by the president of the Institute of Medicine (IOM) with the concurrence of the president of the National Academy of Sciences. The committee met five times in the course of 15 months to develop a study plan, analyze the issues, and make recommendations. The project officer for the study from the Office of the Assistant Secretary for Health and the liaison committee of officials from NIH, ADAMHA, the Health Resources and Services Administration, the Centers for Disease Control, and the Office of the Assistant Secretary for Planning and Evaluation helped the committee gain access to the information necessary for the study. This study, like previous studies of the organization and management of research and service programs in the PHS, attempted to respond to specific questions that involved issues of structure, leadership, and polities. The committee consulted the organizational and public administration literatures, as well as the literature on management of research and development programs, in establishing a framework for the study. This report is an attempt to pull together various ideas current in PHS agencies and to explore the apparent relationships (or lack thereof) between research and service programs in specific cases examined for this study. In order to develop a study methodology and gather information, the committee established seven task forces. A member of the full committee either chaired or was a member of each task force. The task forces included, in total, 23 additional people (Appendix C ); their reports have strongly influenced the deliberations of the full committee as well as many elements of this report. The committee and task forces relied on a series of activities to gather information. Case studies and background papers were either commissioned or written by staff. The committee also reviewed many previous studies of ADAMHA, NIH, and other federal agencies, as well as numerous policy papers on organization and public management issues. In addition, after developing a classification scheme, research grants and services development and demonstration programs and projects were classified (within case study areas) for selected years between 1975 and 1989 to assess changes over time in the research and services portfolios of agencies and institutes. During the course of the study, more than 150 interviews were conducted by staff and consultants. Interviews conducted with current federal officials included agency directors, policy analysts, directors of budget and planning offices, administrators of research and service development and demonstration programs, and scientists. In addition,

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Research and Service Programs in the PHS: Challenges in Organization the directors, presidents, and staff of more than 25 constituency groups were interviewed. The interviews for the case studies and commissioned papers revealed a number of concerns about basic and clinical research training programs, health care financing and reimbursement policies, the long-term impact of dissemination of research findings on changing clinical practice patterns, and the size of allocations to both research and services programs in the PHS. These concerns deserve the full attention of the PHS but are beyond the committee 's charge and thus are not dealt with in detail in this report. Although the committee and task forces tried to be as thorough as possible in gathering objective information, much remains a matter of judgment. In the end, the findings and recommendations of this report are the product of a synthesis of objective analyses conducted by staff and consultants, the informed opinion of a wide range of respondents, committee members' extensive experience, and committee discussions. Notwithstanding the many challenges presented by this study, committee discussions were at the same time both enthusiastic and deliberate. The resulting recommendations address a number of important issues. Throughout the course of this study, the committee benefited from the efforts of the task force participants, all of whom made significant contributions to the study. Important and necessary background materials were provided by John Burckhardt, the study's project officer, and by the members of the liaison committee. Data on grants, without which the study could not have proceeded, were provided by staff in the Division of Research Grants at NIH. The committee is grateful for the valuable contributions and insights of case study writers Kathleen Stratton, Lorraine Klerman, and Carol Blixen; the indispensable work of the writers of commissioned papers, Ruth Hanft, Beryl Radin, Jeffrey Fox, Phyllis Kaye, Sarah Williams, and Richard Schmidt; and the significant contributions of consultant Bob Walkington. The committee could not have met its charge without the expertise and dedication of staff of the Institute of Medicine. The committee wishes to thank the director of the Division of Health Sciences Policy, Ruth Bulger, for her interest and useful suggestions throughout the study. The committee is especially indebted to study director Mady Chalk and her astute management of the entire effort. Her broad knowledge of issues and people, coupled with good judgment, fairness, enthusiasm, and patience moved the study forward efficiently. Kathleen Stratton, the associate study director and a case study writer, with her clarity of thinking, commitment, and good

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Research and Service Programs in the PHS: Challenges in Organization humor, made invaluable contributions to the study. Catharine Chetney, research assistant, expressed interest in specific parts of the study that led to her assuming responsibility for one portion of it. Her willingness to help with the many tasks requested of her was especially helpful. All staff worked long and hard within extraordinary time constraints, given the scope of the study, to accomplish the committee 's task. Beverly Proctor, Louise Gillis, and division secretary Rita Gibson made the meetings for the study in Washington and California comfortable for members and guests of the committee, as well as providing excellent secretarial support. Steven Beering, Chair Committee on Co-Administration of Service and Research Programs of the National Institutes of Health, the Alcohol, Drug Abuse, and Mental Health Administration, and Related Agencies

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Research and Service Programs in the PHS: Challenges in Organization Contents     BRIEF SUMMARY OF RECOMMENDATIONS   1     EXECUTIVE SUMMARY   3      Organizational Goals and Missions   5      Planning and Priority Setting   7      Demonstration and Information Dissemination Programs   8      Duplication, Replication, and Complementarity   10      Final Thoughts   11  1   INTRODUCTION   13      Definition of Key Terms Used in the Study   15      Organization of the Report   15      Organization and Management of the Public Health Service   16      Organization and Mission of the Five PHS Agencies   20      Notes   25  2   A BRIEF HISTORY OF ADAMHA AND PREVIOUS STUDIES OF ITS ORGANIZATION   27      Overview   27      Early History   28      The 1960s   29      The Gardner Report and the Birth of ADAMHA   31      ADAMHA   34      Notes   40

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Research and Service Programs in the PHS: Challenges in Organization  3   METHODOLOGY   43      Overview   43      Categorical Analyses (Case Studies)   44      Nomenclature and Classification   46      Case Study of Alzheimer's Disease   51      Case Study of Substance-Abusing Pregnant Women   53      Case Study of Dopamine Research: Schizophrenia and Parkinson's Disease   55      Functional Analyses   58      Notes   65  4   CO-ADMINISTRATION OF RESEARCH AND SERVICES   69      Overview   69      Research and Service Missions of the PHS   70      The Research–Services Continuum   76      Co-Administration of Research and Service Programs   79      Planning, Priority Setting, and Budgeting   88      Effectiveness of Demonstration and Information Dissemination Programs   94      Organizational Capacity and Program Placement   102      Final Thoughts   105      Notes   106      Additional Bibliography   108  5   DUPLICATION, REPLICATION, AND COMPLEMENTARITY   109      Introduction   109      Definitions   109      Replication, Duplication, and Complementarity in the Case Studies   111      Guarding Against Duplication   116      Notes   117     APPENDIXES    A.   List of Abbreviations   119  B.   Nomenclature for Research and Service Activities   121  C.   Task Forces and Liaison Committee   127  D.   Interview List   131

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