For the Public Good: Highlights from the Institute of Medicine, 1970-1995 (1995)

by Marion Ein Lewin, M.A.

Director, Office of Health Policy Programs and Fellowships

No commemoration of the Institute of Medicine's (IOM's) 25th anniversary would be complete without mention of the Robert Wood Johnson (RWJ) Health Policy Fellowships and the Pew Health Policy program. Both of the programs have had a long and distinguished tenure at the IOM. The RWJ Fellowships program has been directed at the Institute since 1973. The Pew Health Policy program has been administered at the Institute since 1988, although it has been in existence since 1982. These two midcareer training and leadership programs, while different in a number of important ways, have both made significant contributions to the career development of health care leaders as well as to the field of health policy formulation, health services research, and the capacity of academic health institutions to develop an effective interface with the political system.

The RWJ Health Policy Fellowships program is designed to develop the capacity of outstanding midcareer health professionals working in academic institutions and community-based health care delivery systems to assume

leadership roles in health policy and management. Six Fellows are selected on a competitive basis each year to participate in a 1-year program of orientation and full-time work experience in the nation 's capital. Fellows are selected from academic faculties in medicine, dentistry, the biomedical sciences, nursing, public health, health services administration, the allied health professions, economics, and other social sciences. Candidates must be nominated by the deans or chief executive officers of their institutions. To reflect the changing health care marketplace, eligibility for the program was broadened in 1994 beyond academic health centers to include other providers and institutions in the health care system, such as HMOs and related community-based organizations. Including the current 1994–1995 class, 127 Fellows from 65 academic institutions have participated in the program.

The RWJ Fellows arrive in Washington, D.C., in early September to begin an 8-week orientation period arranged by the IOM. Fellows meet with key White House advisers; top administrators of agencies responsible for health activities; congressional committee staff members; and representatives of health policy think tanks, research, and interest groups. Also included during this period are seminars on health economics, the budget process, and the politics and process of federal decision-making.

In subsequent weeks the RWJ Fellows join with the American Political Science Association Congressional Fellows for sessions with senators, representatives, and other experts on the national, political, and governmental processes. During this time, Fellows contact congressional offices that have an active interest in health issues and, in consultation with the program director, negotiate their working assignments. Most of the Fellows decide to work in Congress, particularly in the Senate, but assignments in the executive branch also are possible (see Table 1).

The Pew Charitable Trusts established the Pew Health Policy Program in 1982 to train leaders in health care. It was the foundation's first Trust-initiated program. The program was developed in response to the realization that the growing scope and complexity of the U.S. health care system called for an expanded effort in health policy education and research. At the time, a special advisory group to the Trusts identified the importance of enhancing opportunities for advanced-level interdisciplinary training to include academicians, economists, lawyers, managers, physicians, politicians, and other health professionals. The Trusts and the advisory group believed that in order to develop

and evaluate promising options for change and to work toward sound, lasting solutions, a diverse set of key players and researchers needed to be armed with a solid foundation of theoretical, analytical, and applied skills to enable them to work together to address real-world problems.

To respond to the need, Pew selected four institutions with demonstrated capabilities in health policy development and education to sponsor specialized training programs in health: Boston University/Brandeis University; the University of California, San Francisco; the University of Michigan; and RAND/ University of California, Los Angeles (UCLA). The program was re-funded in 1987 and again in 1991, with all programs except RAND/UCLA accepting new students. The Pew Health Policy Program at each site has a distinct character and orientation. Brandeis University offers an intensive 2-year, interdisciplinary program leading to a Ph.D. The University of Michigan has a 3-year, nonresidential program designed so that students can remain employed full-time while obtaining their doctorate. The University of California, San Francisco, provides primarily 2-year postdoctoral and midcareer fellowships to social scientists, physicians, and other health professionals. Today, more than 256 graduates hold positions at all levels of government, in academic institutions, in the corporate world, and in nonprofit organizations. The network of Pew Fellows spans the United States, stretching to Canada and overseas.

The IOM Office of Health Policy Programs and Fellowships functions as the program office for this endeavor. The office directs and coordinates the

joint activities of the Pew Health Policy Program, including convening conferences and producing various related publications. The office also fosters linkages among Pew Fellows, the program of studies at the IOM, and the Washington health policy community.

As documented in various informal and formal evaluations conducted over the years, both the RWJ and the Pew programs have been successful in achieving many of their original goals and objectives, particularly in the areas of career development and facilitating the opportunity for midcareer health professionals and health policy researchers to become more effective participants in the world of health policy, health policy research, and public affairs. The programs' success is reflected in part by the ongoing funding support that they have received from their foundation sponsors: the RWJ Health Policy Fellowships program is now in its seventh grant cycle, the Pew Health Policy Program in its third. These programs have continued to evolve in a number of significant ways to reflect new realities, priorities, and dramatic changes in the organization and financing of health care services. In the case of the Pew program, focused efforts have recently been directed at institutionalizing the training programs at the three sites so they will continue to operate after current funding comes to an end.

In 1991, prior to the most recent 5-year renewal of the RWJ Fellowships program, the foundation commissioned a major external evaluation of the program by David Blumenthal (Blumenthal et al., 1992). The chief evaluation findings were published in the spring 1994 issue of Health Affairs (Meyer et al., 1994). The evaluation asked two questions with broad policy relevance: (1) Can an intense exposure to health policy lead health professionals to lifelong involvement in policy issues? (2) Can fellowships affect the careers of health professionals? Parallel surveys, using standard techniques, were sent to all former Fellows and to nominees who were chosen as finalists in the selection process but failed to gain admission to the program.

Results of the evaluation indicate that the program has been most successful in achieving its goal of assisting the personal career development of midcareer health professionals. The fellowship also has helped to improve the policy-making process by bringing to bear the expertise of health professionals who would not otherwise have been available to that process. The findings showed that Fellows and finalists were very similar in their levels of accomplishment before they encountered the program and remained similar after-

ward. Their careers differed primarily in their commitment to health policy and public affairs. In their academic lives, Fellows were more likely than finalists to have been involved in one or more activities related to health policy. As private citizens, Fellows were significantly more likely than finalists to be involved in the affairs of state and federal governments, academic administration, and community and professional activities. Government service, one of the original goals of the program, has not been a prominent part of the lives of most program alumni.

The Blumenthal evaluation also tried to assess whether or not the RWJ Fellowships helped make academic medical centers more socially responsible and responsive, an outcome that the program sought to advance after it had been in operation for a number of years. A survey of past Fellows and academic medical center leaders on this question indicates that this goal also may have been achieved. Former Fellows returning to their institutions created an academic health policy presence on the faculties of professional schools and broadened the capacity of these institutions to relate to government and local communities.

According to the evaluation surveys, Fellows generally seem to feel that the program has had a significant effect on their careers. A majority of alumni responded that it helped “a lot” in achieving their career goals. When asked to characterize the fellowship, substantial majorities of Fellows credit it with exerting a major impact on their lives and careers. For example, 81 percent said it “changed the way I think” and 60 percent said it “changed my life”¹ (see Table 2).

Fellows also believe that the fellowship has enhanced their effectiveness in a number of areas of their professional lives including teaching, working with

the federal government, working with their professional organizations, and community service (see Table 3).

As a result of the evaluation findings, certain aspects of the fellowships program were modified in conjunction with a 5-year renewal. The fellowships program continues to have a preponderance of physicians and health professionals from academic health centers, but now has a greater openness to other disciplines and career settings, such as managers of health care plans and social scientists. Further, the role of states in health policy reform has grown and developed over the almost 25 years of the program. In keeping with this enhanced state role, Fellows will be encouraged to develop linkages with state governments during their fellowship year.² A site visit to a state that has designed an interesting and innovative program is now a central component of the program.

The Pew Health Policy Program was evaluated in 1985 and 1990 by Bill Richardson,³ who at the time headed the program's advisory board. In 1994, the program underwent another evaluation conducted by the firm of Hamilton, Rabinovits & Altschuler, as part of a broader inquiry into the impact of the Pew Charitable Trusts ' “signature” programs. The report has not been completed, and only partial findings have been released to date.

During the first two grant cycles of the program, primary efforts were placed on creating a solid institutional base for training a cadre of midcareer health professionals and policy specialists who could apply theories and techniques to answer real-world problems and who were willing to make policy decisions under high-risk conditions. In the early evaluation, program success was measured primarily by the quantity and quality of interested students enrolled in the program and their ability to succeed in a fast-track doctoral program. In the 1990 evaluation, program alumni saw as the most influential aspect of the program its effect on the caliber of their job performance. The program was not deemed to be influential in helping alunmi to obtain the positions they held. This is partly explained by the nature of the Michigan program, where Fellows do not have to leave their jobs in order to pursue their doctoral training. The 1990 Richardson evaluation recommended that the program become a “signature” program of the Pew Charitable Trusts and be renewed for another 5 years. The evaluation commended the IOM program office and its effective work in helping to link separate scholarly training efforts into a “community of scholars with a special identity and national recognition.” The program office also was praised for its effectiveness in helping Pew Fellows gain important exposure to the Washington policy and political environment.

With a solid institutional base for training in place, focused efforts are now directed in two areas: (1) moving beyond the training of competent researchers and practitioners to ensuring that the graduates are effective, relevant participants in the health policy process, and (2) legitimizing health policy research as an academic pursuit and as a respected academic discipline. A recent 2-year extension of partial funding by the Trusts to the three program sites is focused on helping the sites to institutionalize their program when Pew funding ends.

In a preliminary report of the not-yet-completed Hamilton, Rabinovits & Altschuler evaluation, the evaluator offered his personal impression of the impact of the Pew Health Policy Program:

the Pew Health Policy Program was one of the early and influential stimulants to what became, over time, a sizable expansion of rigorous health policy training during the past dozen years. This, has, in turn, elevated the technical debate about health policy options and implementation to a markedly more sophisticated level. . . . It can be argued that this crescendo of intellectual interest and training in this field is an inevitable concomitant of the commanding role played by mushrooming health care costs in public budgets and in the economy more generally. But The Pew Charitable Trusts was ahead of most other major private funders in perceiving the importance of cross-disciplinary training in this area, and its 245 trainees, while not a substantial fraction of all individuals employed by public and non-profit entities in positions like the ones they occupy, seem likely to make up a non-trivial element of the vanguard of such people who have emerged as the health

policy debate has gathered strength. It is much less clear, at least to this evaluator, how successful the Program has been at legitimizing advanced health policy studies as an academic or career pursuit. . . . In all cases, the acid test of legitimization at the grantee institution itself is whether the activities will survive after The Pew Charitable Trust umbilical cord is cut.

According to surveys and evaluations, both of the fellowship programs have benefited significantly from their linkage to the IOM. A number of these benefits have already been described in this paper. Of the two programs, the RWJ program has had a closer relationship with the Institute because the Fellows are based in Washington during their fellowship year.

As part of the grant requirement, RWJ Fellows have to submit a written evaluation of their fellowship experience at the end of their Washington stay. Over the years these evaluations have provided ample and sustained evidence of the many ways in which Fellows' experiences have been broadened and enriched by the IOM connection. The Fellows feel privileged to be an integral part of a prestigious institution like the IOM, to be warmly welcomed and mentored each year by the IOM's senior professional staff and executive officers, and to be enthusiastically invited to participate in IOM study activities. In turn, the IOM 's program activities gain from the Fellows' professional backgrounds and experiences, as well as the valuable policy and political intelligence they are able to provide from the perspectives of their working assignments in the Congress or executive agencies. The unique synergism between the two entities reached a new height late last year when Karen Hein, M.D., a 1993–1994 Fellow, became executive officer of the IOM.

Over the years, Pew Health Policy Fellows have forged a closer relationship to the IOM as well, even though most Fellows formally interface with the IOM only once during their Pew program training—during the Washington briefing for new Fellows each fall. At this meeting, information about the IOM is disseminated and IOM reports of special interest are showcased. Knowledge about the IOM and interest in its program activities also are furthered by the program directors at each of the three sites, most of whom are IOM members.

It is interesting to note that at present, 36 current and former Pew Fellows are in Washington, working in senior positions in agencies and organizations such as the Department of Health and Human Services, the General Accounting Office, the National Institutes of Health, the Agency for Health Care Policy and Research, the Office of Technology Assessment, the Agency for Health Sciences Research, the Prospective Payment Assessment Commission, the Physician Payment Review Commission, the Urban Institute, the American Hospital Association, and at Georgetown and Johns Hopkins University Hospi-

tals. In addition, a Pew alumni has recently been appointed director of the Division of Social and Economic Studies in the Commission on Behavioral and Social Sciences and Education of the National Research Council.

In preparation for this report, the Office of Health Policy Programs and Fellowships conducted an informal mail survey to get a better sense of the degree to which RWJ and Pew alumni have been involved in IOM activities. Seventy-five percent of RWJ alumni responded, and almost 50 percent of them said that they had been involved in some kind of IOM activity, ranging from membership in the IOM (five, or 4.6 percent); to serving on an IOM committee (25 percent); to having been a speaker or presenter at an IOM activity (20 percent). ⁴

Forty percent of Pew alumni responded to the survey, and of that group almost 20 percent reported participation in an IOM activity. One Pew alumnus is an IOM member. Almost 6 percent of those who responded had served on an IOM committee. These numbers, while low, are quite impressive given that Pew Fellows tend to be considerably younger and at a less senior stage in their career than RWJ Fellows. A number of RWJ and Pew alumni (14 percent and 11 percent, respectively, of those responding to the survey) stated that they “would like to be involved in an IOM activity but have not been asked to do so.”

The ongoing success and accomplishments of the RWJ Health Policy Fellowships Program and the Pew Health Policy Program in the world of health policy, health policy research, and public affairs have been amply documented. Both of these programs are now well established and nationally recognized. The importance and relevance of these programs to the changing landscape of health care financing and delivery is underscored not only by the long-term foundation support they have received, but also by the leadership roles RWJ and Pew alumni now play at academic institutions and in health care and health policy organizations across the land, in public agencies, in the not-for-profit sector, and in corporate America. The IOM has been an important and valued contributor to the success and impact of these fellowship pro-

grams, providing a rich intellectual environment that has greatly broadened and enhanced the context and scope of the fellowship endeavors.

Blumenthal, D., Meyer, G.S., and Edwards, J.N. 1992. The Robert Wood Johnson Foundation Health Policy Fellowships: An Evaluation. Boston: Health Policy Research and Development Unit, Massachusetts General Hospital.

Meyer, G.S., Edwards, J.N., and Blumenthal, D. 1994. GrantWatch. Health Affairs Spring(II):264–70.