The Lessons and The Legacy of the Pew Health Policy Program



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The Lessons and The Legacy of the Pew Health Policy Program The Lessons and The Legacy of the Pew Health Policy Program

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The Lessons and The Legacy of the Pew Health Policy Program The Lessons and The Legacy of the Pew Health Policy Program Jon A. Chilingerian Corinne M. Kay INSTITUTE OF MEDICINE SPONSORED BY THE PEW CHARITABLE TRUSTS

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The Lessons and The Legacy of the Pew Health Policy Program NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the 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 adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by The Pew Charitable Trusts, Philadelphia, Pennsylvania. Additional copies of this report are available from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). http://www/nap.edu. Copyright 1997 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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The Lessons and The Legacy of the Pew Health Policy Program Foreword This document describes the creation, evolution, and future opportunities in health policy training that have emanated from The Pew Charitable Trusts' l5-year support of the Pew Health Policy Fellows Program. It is intended to help stimulate and strengthen health policy training programs at a time when rich and diverse approaches are so crucial to preparing leaders to deal successfully with the many compelling health care delivery and financing issues that we face as a nation. The document portrays the strategic approaches taken over the life of the program, as well as their strengths and weaknesses, conveys a sense of optimism about how much can be achieved by creating an environment in which talented people can learn new skills to use in analyzing problems and devising improved policies for addressing them. In 1982, the Pew Charitable Trusts initiated the Health Policy Fellows Program, with a grant of $11.85 million. The program was based on a premise that the challenges that lay ahead in health care would require a cadre of people with finely honed skills to analyze issues and to translate those analyses into public policy. The program was also an attempt to bridge the gap between policy research and policy-making, and to infuse a variety of perspectives into the search for ways to improve access to and the quality of health care while controlling its cost. At that time, there were few places where this kind of multidisciplinary environment flourished. Instead, people interested in pursuing health policy research usually defaulted to discipline-specific academic departments and, if they were highly motivated, sought perspectives from other fields and disciplines. The Pew program was an attempt to break down barriers, to stimulate the creation of a multidisciplinary training environment, and to promote an interchange among policymakers, academic faculty, and students. It was also designed to apply rigorous methodologi-

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The Lessons and The Legacy of the Pew Health Policy Program cal approaches to applied health policy research. These goals and changes were fundamental to the program's success, and achieving them required the dedication, commitment, and foresight of project directors and faculty in each of the participating sites. In the early years of the Program, four sites were funded, each of which is described in the pages that follow. The University of Michigan program offered people working full time, often in government, the opportunity to pursue a doctorate through weekend sessions and through work on a dissertation topic related to their job. Boston University and Brandeis jointly offered a 2-year doctoral "corporate fellows" program for high-level executives in the health care field, and an "associates" program to provide technical assistance to select cities. The University of California San Francisco (UCSF) program offered a 2-year predoctoral fellowship and postdoctoral opportunities for health care professionals. Last, the RAND/University of California Los Angeles (UCLA) program offered a 2-year doctoral degree and a 1-year (nondegree) midcareer fellowship designed primarily for academic health care professionals. The four programs ran the gamut in terms of enabling people at any stage of their career—whether at a predoctoral, postdoctoral, or corporate continuing education level—to develop the skills needed to become leaders in health policy research and policy-making. Funding for a central administrative office was provided initially to the American Enterprise Institute and later to the Institute of Medicine, to support Marion Ein Lewin's leadership and direction of the program. From the beginning, she worked tirelessly to guide the implementation of the program by its leaders at the four sites: Richard Egdahl and Stuart Altman at Boston University/Brandeis; Albert Williams at RAND/UCLA; Philip Lee and Carroll Estes at UCSF; and John Griffith and Leon Wyszewianski at Michigan. Early Fellows were guided through their studies by the likes of Steve Crane at Boston University, Kate Korman at RAND/UCLA, and David Perlman at Michigan. Early advisory committee members who helped critique and refine the program included Bruce Vladeck (chair), Bob Blendon, Walter McNerney, Judy Miller-Jones, Bill Richardson and Gail Warden. Following Dr. Richardson's thoughtful evaluation of the program in 1985, the Trusts renewed their commitment with an $8.1 million grant. The advisory committee added new experts as well, including Diane Rowland (chair), Richard Curtis, David Kindig, Faith Mitchell, and

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The Lessons and The Legacy of the Pew Health Policy Program Helen Smits. The sites continued to modify and refine their efforts based on the advisory committee's recommendations, and in 1991 the grant was renewed one last time for $5.7 million. This time, however, the funding supported three distinct models: the UCSF postdoctoral program, directed by Hal Luft and Carroll Estes; the Brandeis University doctoral program codirected by Stan Wallack and Jon Chilingerian; and the continuation of the Michigan nonresidential program for full-time workers, directed by Bill Weissert. Several common themes transcended the different program structure. For instance, Fellows and faculty alike flourished thanks to the commitment of the faculty in fusing a direct link between theory and practice. Most faculty moved easily between policy research and policy-making, thus demonstrating for students that this divide was an artificial construct that could be traversed effectively. Second, all of the programs were sharply focused. It is easy in a multidisciplinary environment to become vague and fuzzy. Instead, the programs required strategic thinking on explicit topics. The topics could be synthetic (i.e., systems approaches) rather than reductionist, but underlying the topical framework was a third shared characteristic: methodological rigor. Fourth, the Fellows learned from one another as well as from their faculty mentors, and this created a strong network of leaders who soon became mentors in their own right. Throughout the program's 15-year history, the sites incorporated the lessons they learned as they worked to reconcile the tensions that naturally arose between conflicting demands. For example, there is always a tension between breadth or depth in multidisciplinary studies, and each program took its own road in defining the appropriate balance. Moreover, applied research methodologies inherently call for trade-offs between pragmatic constraints and research design needs. Finally, all programs entered into the final several years of funding recognizing that the Trusts' support was coming to an end, and that the their future viability would depend on finding other sources of support. Their continued viability also would require a willingness by the sponsoring universities to "institutionalize" this multidisciplinary approach and to legitimize health policy research as an academic discipline. Recognizing that its support could facilitate only a handful of models, and appreciating how much these models have to contribute to the field, the Trusts requested that the project leaders develop the present document so other institutions could benefit from the programs' experiences—both their successes and their problems—and might

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The Lessons and The Legacy of the Pew Health Policy Program develop their own health policy training programs to expand the available options for interested students. The network of Fellows is now more than 300 strong. Many of the alumni play leading roles in policy-making positions in both the public and private sectors as well as in academia throughout the country. We owe the early faculty and Fellows a great debt of gratitude for taking the risk of entering into a new type of program and for establishing ties with and mentoring new Fellows. We are grateful to the Fellows of the early 1980's for strengthening the programs through their candid feedback and critiques. We owe the current Fellows special thanks for enrolling in the program during this time of transitional funding, when they and their faculty have had to rely on creative means of generating additional support. We are greatly indebted to the faculty for their unflagging commitment to the program, and for their devotion to making it better year after year. We are enormously grateful to Marion Ein Lewin who has directed the program for 15 years, has facilitated its refinement and evolution, and has served as its enthusiastic advocate and emissary. Finally, we owe a tremendous debt of thanks to the sites, advisors, Fellows, and alumni for their candor in sharing their experiences and thoughts in this document, and to Jon Chilingerian and Corinne Kay for pulling all of this material together to create what we hope will be a useful resource for years to come. Of course, the good works of the over 300 Fellows and alumni are a legacy of their own. Carolyn H. Asbury, PhD Director, Health and Human Services The Pew Charitable Trusts Philadelphia, Pennsylvania April 24, 1997

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The Lessons and The Legacy of the Pew Health Policy Program Acknowledgments Books are rarely creations of their authors alone; rather they synthesize and build on the ideas, opinions, and work of many. This "legacy" is an example of that fact. We have relied on archival materials, program evaluations, and interviews with dozens of Pew Fellows, program staff and faculty, and Institute of Medicine staff. Grateful acknowledgment is made to those who allowed us to carry forward their knowledge and ideas, especially those who were part of the focus groups (Washington meetings in November 1995 and December 1996 and Atlanta meeting in June 1995) and to the BU/Brandeis Pew Fellows who were in Jon's Pew Seminar. We are happy to thank all those many friends who shared and helped us, especially the interviewees who not only gave of their time to discuss their Pew experiences but then meticulously read through sections of the document and provided helpful comments. They are (in alphabetical order): Stuart Altman, Dennis Beatrice, Lisa Bero, Sarita Bhalotra, Patricia Butler, Steve Crane, Joan DaVanzo, Carroll Estes, Kathleen Eyre, John Griffith, Terry Hammons, Jonathan Howland, Kate Korman, Leighton Ku, Mark Legnini, Marion Ein Lewin, Hal Luft, John McDonough, Pamela Paul-Shaheen, Dan Rubin, Stan Wallack, Linda Simoni-Wastilla, Bill Weissert, Al Williams, and Leon Wyszewianski. Furthermore, there were several Pew alumni who were not interviewed but who graciously reviewed sections of the document and provided suggestions: Nora Maloy (Michigan), Debbie Ward (BU), Linda Bergthold (UCSF), Ruth Malone (UCSF), and Faith Mitchell (UCSF). Their criticism guided us. If, in places, we did not take their advice, we alone are to blame. We would also like to express our gratitude to Kevin Dombkowski, a current Michigan Pew Fellow, for his valuable assistance with graphics.

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The Lessons and The Legacy of the Pew Health Policy Program We are deeply indebted to Marion Ein Lewin for all her help in the construction of this book. Our gratitude also goes to Shirley Stewart for her assistance in getting the project started and locating some interesting archives, Carolyn Asbury for writing the preface, and Stan Wallack and Steve Crane for their stimulating comments on the manuscript. Special thanks to Valerie Tate Jopeck for her great patience and exceptional organizational skills and to Nancy Marley and Kathleen Keck for their most expert assistance in preparing the manuscript. We thank Michael Hayes for his help in editing this book, and to Linda Humphrey for her inspired design work. We are grateful to Dean Jack Shonkoff for his kindness in providing us with a haven to do this work. Thank you Dianne, Christine, Johnny, and Chris (with love). Last but not least, we would like to thank each other for the pleasure of working together to complete this project. It was fun. Finally, we dedicate this book to the Pew Fellows, in recognition of their sacrifice, interest, criticism, and deep concern for the future of our health care system.

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The Lessons and The Legacy of the Pew Health Policy Program Contents Foreword by Carolyn H. Asbury   v Acknowledgments   ix Part I. Introduction   1     The Birth of the Pew Health Policy Program   2     Vague Goals that Allowed for Reflective Organizational Learning   6     History and Origins of Development   7     Program Descriptions   8     The Role of the IOM   17     Notes on Program Strengths and Weaknesses   19     Common Themes   33 Part II. Successes and Failures   35     Critical Success Factors   35     Recruitment   35     Mentoring   42     Community of Scholars   45     Early Focus on the Dissertation   48     Networking   51     Multidisciplinary Education and Training   55     Leadership Roles   59     The "Price" of Institutionalization—Financing Issues   62 Part III. Determining the Legacy   69     Where Are the Pew Fellows Today?   69     Importance of Doctoral Degree Completion   77     Uncovering the PHPP Legacy   81     Answering Future Needs and Offering Advice   91

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The Lessons and The Legacy of the Pew Health Policy Program Part IV. Summarizing the Legacy: Some Conclusions and Thoughts for the Future   95     A Strategic Framework for Analyzing the PHPP Experience: Basic and Integrative Elements   96     Developing Strategic Program Visions: Integrative Elements   105     Implications for Developing Health Policy Programs as a New Educational Niche   112     Summarizing the Lessons Learned: Maxims for Other Schools   116     Highlighting Collective Accomplishments and Program Impacts   124     Envisioning a Future Policy Role for Pew Fellows   128 References   133 Appendix A. Telephone Interviews   137 Appendix B. Curriculum and Course Offerings   301 Appendix C. UCSF Fellow-Mentor Arrangements   331 Appendix D. Examples of Career Trajectories   339

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The Lessons and The Legacy of the Pew Health Policy Program List of Tables Table 1.   Health Advisory Group Membership, The Pew Charitable Trusts, 1980   3 Table 2.   Breakdown of Career Categories, 1996   73 Table 3.   Professional Distribution of PHPP Alumni at the Start and End of Program, in percent   75 Table 4.   Proportion of Pew Doctoral Fellows Who Completed Degree, by Program Site, 1996, in percent   77 Table 5.   Positioning of the Pew Health Policy Program Versus Traditional Doctoral Programs   108 Table 6.   Migration Paths of Pew Fellows by Program Site Before and After Attending the Program   125 List of Figures Figure 1.   Professional Distribution of PHPP Alumni by Site, 1996   71 Figure 2.   Developing Niche Educational Programs: Basic and Integrative Elements   97

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