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

by Stuart H. Altman, Ph.D.

Sol C. Chaikin Professor of National Health Policy and Former Dean of the Heller School for Social Policy, Brandeis University

In my travels to other countries and in discussions with experts on various health care systems around the world, it has become clear that one of the many differences between the United States and other countries is the role and importance of the so-called outside expert in the development of U.S. health care policy. Whether due to the sheer complexity of our health care system or to the peculiarities of our political decision-making processes, an astounding number and diversity of individuals are frequently called on by agencies of the federal government, members of Congress, authorizing or appropriating congressional committees, or even the president and his cabinet to advise on health policy matters. The appropriate experience and expertise of these individuals is a matter of debate. Of course, there is also the question of whether all this advice leads to a better outcome in terms of policy. Yet, as a “policy wonk,” it is difficult for me to think that this is not so.

The vast majority of experts called on by decisionmakers represent an intellectual elite of “nonparticipants” who have never been engaged directly in the provision of the services being reviewed. Physicians, nurses, hospital administrators, and other health professionals often have been missing from the policy-making circle. This did not occur by accident. The conventional wisdom of those involved in the policy process was that these hands-on professionals both lack the necessary training to substantively critique the system in which they work and are motivated by a strong vested interest in a particular outcome. As a founding member of the “Society of Outside Ex-

perts,” I must confess that I, too, have had such thoughts. Moreover, those of us who strive for “objectivity” as our central credo point to the large lobbying “war chests” of these same professional interests and their national organizations. There is also the question of whether any training other than economics, or possibly political science, has any relevance to the policy process. For those of you who are not economists, this thought might be slightly incredible. Could anyone even think this? I'm afraid there was a sizable group in the 1960s and 1970s who believed this was true.

Finally, there is the question of a proper appreciation of the policy process. How can one really advise decisionmakers if he or she does not understand the process by which policy is made and the issues that are important in the policy process? Here, too, I have been guilty of believing that professional training in how to perform complicated open-heart surgery does little to provide any special insight into how to restructure the tax code to finance health services for the poor, or into what role the federal government should play in revamping the health care delivery system.

Yet, despite these admittedly self-interested misgivings of my youth, I have come to appreciate the fact that the United States could truly benefit from the expertise of individuals who understand both how health services are delivered and how health policy is made. Individuals educated to appreciate and apply the analytic tools of various disciplines must be a part of the policy advisory process. Even more so, I now understand that no one discipline has the corner on the market regarding insight into public policy. No one paradigm is sufficient for addressing the policy challenges we face in the health arena. The sheer magnitude of the clinical, organizational, operational, economic, and political considerations involved in health care policy requires that a diversity of perspectives are thoughtfully addressed in evaluating any policy option. Unfortunately, this is often not the case, and the result is a constellation of interests polarized between policy experts who know the inner workings of the policy world and health care professionals who actually deliver health care. This polarization is not in our nation's best interests. In the same way that the advent of managed care no longer allows the physician to make decisions independent of larger considerations about the most cost-effective use of limited resources, current policy-making demands an integrated approach that reflects the insights of both those who actually deliver care and those who understand the financial, political, and social aspects of policy development.

The future of our health care system depends on policy decisions that reflect the problem-solving strategies of different disciplines and perspectives. We need a cadre of trained professionals who can appreciate both the clinical and the practical implications of a certain policy option, along with its political and economic implications. Fortunately, a growing number of

individuals have entered the policy-making process with such interdisciplinary skills.

In terms of educating health care professionals about the policy process, no organization has done more than the Robert Wood Johnson (RWJ) Foundation, which has supported a program administered by the Institute of Medicine (IOM) for the past 23 years. This fellowship program offers the opportunity to eliminate the distance between “outsider” and “insider” in the policy process by turning out professionals with expertise in both the process and the content of health care policy. The RWJ Health Policy Fellowships program has trained more than 125 midcareer faculty from prestigious academic institutions to take on new leadership roles in health policy and management. As discussed in the chapter by Marion Ein Lewin, these individuals leave their normal work environment for a year and participate in a series of activities designed to give them firsthand understanding of the policy process in Washington, I know personally a score of people who have returned from their year of policy work in congressional offices or in the executive branch with a new appreciation of the policy process, and with a realistic understanding of the economic and political considerations that must be addressed in any public policy debate. In their in-depth evaluation of the RWJ program, Dr. David Blumenthal and coworkers * also highlighted the positive impact that many former fellows have had on the faculties and institutions to which they returned. Others have stayed active in the policy process and have been effective participants. Several were important participants during the design and debate of President Clinton's plan for national health reform. Alumni of the program also have taken leadership roles in state health care reform efforts and in operating state health programs.

A newer, but no less important, program administered by the IOM is the Pew Health Policy Program, financed by the Pew Charitable Trusts. This program tackles what some believe is the great divide between health economists and other disciplines, bringing the synergy of an interdisciplinary approach to problem-solving. Established in 1982 and administered by the IOM since 1988, this program has produced a cadre of more than 250 health policy professionals. There are actually four distinct programs, with the University of California/RAND and the University of California in San Francisco offering postdoctoral training; the Brandeis University/Boston University program providing a full-time interdisciplinary doctoral program in health policy; and the University of Michigan operating a part-time doctoral program for people working in the field.

The Pew program offers a truly unique opportunity for advanced interdisciplinary training in each of the four sites. Fellows come from various disciplines, including economics, political science, sociology, law, medicine, and other health-related professions. The program fosters a cross-fertilization of different theoretical perspectives, as well as different methodological approaches in solving concrete policy problems. For example, a deeper appreciation of the dynamics of competing political interests and how these interests are played out in the policy process offers a useful complement to an understanding of the economic implications of a specific financing strategy proposed for Medicare. In the same way that the RWJ program provides an environment of understanding between hands-on managers and clinicians and those familiar with the policy process, so too the Pew fellowships offer a creative linkage between the old vanguard of health policy analysts and those with a more interdisciplinary approach.

Marion Lewin offers dramatic proof of the value of such individuals to the policy process. The Pew program has also had a positive impact on the host institutions. As dean of the Heller School at Brandeis during much of the program's tenure, I can attest to its importance in changing and enhancing the educational environment of the school. The Heller School has had a long history of interdisciplinary training. Clearly, the Pew program enhanced that history—but it did even more. The students recruited were consistently among the best of the Heller applicants. They brought with them a level of experience and commitment to intellectual purity that was infectious. You could feel the difference in the classroom. Non-Pew students had new role models. The program will be missed.

One of the ongoing issues of an interdisciplinary project such as the Pew Health Policy Program is the tension between depth and breadth. I believe this is a particular concern for those Pew fellows participating in doctoral-level training. Perhaps IOM's 25th anniversary is an opportunity to revisit the debate and consider whether the value of attaining the skills to approach a problem from an interdisciplinary perspective outweighs the possible limitation of not being adequately grounded in any one discipline. Although one might argue that doctoral-level training should be grounded in a particular discipline to ensure analytic depth and rigor, I believe the Pew programs address a critical niche. This is particularly true for individuals who do not plan to join the academic ranks. Instead, Pew fellows are better trained to bridge the gap between policy research and policy-making. They will probably be more successful in the private corporate and nonprofit sectors or in government service. In terms of their positive impact on concrete public policy development, the Pew programs have been quite successful in producing highly trained, analytic thinkers able to appreciate the complex context of policy.

We need to expand the number of professionals with such training to engage in public policy development. These individuals have the analytic training and capacity to draw from multiple theoretical frameworks, to apply those methodological approaches most appropriate to the policy dilemma at hand, and to undertake this interdisciplinary work with a thorough understanding of the workings of the policy process. I was wrong in my youth and now acknowledge that each discipline is laden with its own internal biases and traditional parameters that limit the horizon of our thinking and the range of possibilities that we are open to considering.

The Pew Charitable Trusts and the RWJ Foundation are to be commended for their foresight and commitment in making the kind of long-range investment required to develop this important cadre of interdisciplinary professionals. It takes a rare level of commitment to make such a longterm investment in the future when today's focus is so often on immediate and concrete results. While long-term funding of such programs represents a sizable commitment on the part of sponsoring foundations, the contribution of these programs cannot be underestimated. Steve Schroeder, in his chapter, acknowledges that strong pressures exist at foundations not to fund such programs because of their cost and the lack of immediate results. I would be less than candid if I failed to indicate my sadness at learning that the Pew Charitable Trusts had decided to discontinue funding this fellowship program. The Trusts were generous in providing a last grant to assist host institutions in developing self-sustaining funding for these programs, but I am not optimistic. The number of organizations that have the financial capacity to take on this commitment is extremely small.

However, this is not the time to be negative. These have been two great programs. No small part of this success goes to the IOM and especially to the director of the program, Marion Ein Lewin. Clearly, one of the strongest aspects of the Pew program and central to the RWJ program has been the networking among the fellows in each program, between the fellows in the different programs, and between the fellows and those engaged in the Washington policy process. The IOM made this happen. It created the structure and environment in which these programs, and the individuals participating in them, could maximize their contribution to national and local policy development. I would hope that even without the substantial funding that these programs required, the IOM would continue to offer such activities in the future. As a seasoned “outside expert,” I applaud the IOM's work in adding depth and expanded opportunities to these uniquely trained individuals.

by Steven A. Schroeder, M.D.

President, The Robert Wood Johnson Foundation, Princeton, N.J.

My remarks about the Robert Wood Johnson (RWJ) Health Policy Fellowships program and the Pew Health Policy Program will focus on their impact on the three sets of involved institutions—the Institute of Medicine (IOM), the sponsoring foundations, and the academic sponsors—as well as on the fellows themselves.

Operating ongoing programs is an unusual activity for an organization such as the IOM, which is best known for its honorific membership and scholarly reports. The IOM's usual activity is the conduct of specific, in-depth analyses. As a result, most of its work either recognizes past accomplishments or addresses the state of the current knowledge base. By contrast, fellowship programs are an investment in the future, and health policy fellowships focus on the health policy process rather than on a discrete knowledge base. As such, of course, the fellowship programs fall outside the National Academy of Sciences intensive review process.

Another difference is age. Both sets of fellows, but especially those in the Pew program, are considerably younger than most IOM members as well as most of those nonmembers who participate on project committees by dint of their professional expertise. Whereas the average age of IOM members is over

50, Pew fellows are commonly in their 30s and RWJ fellows are in their 40s. Working with comparatively young professionals whose careers are still unfolding poses different challenges and brings different responsibilities than relating to mature members contributing in their areas of content expertise.

During the life of these two programs, their subject matter—health policy—has become an increasingly central focus of national attention, driven largely by concerns about relentlessly rising medical expenditures. As a result, the IOM's interests and programs are now more closely aligned with the activities of the fellowship programs than they were when the RWJ program began in 1973. It is logical to assume that this closer alignment has benefited the work of the IOM, and indeed the chapter by Marion Ein Lewin suggests that it has.

For example, the RWJ program provides formal linkages to the Washington policy-making process. The first such linkage occurs during the orientation phase, when prominent policymakers provide the fellows with an insider 's view of health policy. Subsequently, the fellows undergo an intensive round of interviews with staff of key congressional committees. Finally, the fellows' experiences on Capitol Hill are closely monitored by the IOM. Presumably, these experiences, repeated and reinforced annually, could supplement the knowledge of the IOM about health policy issues. This, in turn, could result in greater timeliness and policy relevance in the selection and execution of policy-related projects by IOM.

Similarly, the Pew program provides formal linkages to top academic health policy institutions and their faculties. As with the RWJ program, such intellectual linkages should expand the knowledge and the network of the IOM and thereby benefit its formal projects. In addition, participating in a fellowship program should familiarize the IOM with the difficulties that confront young professionals embarking on interdisciplinary careers, issues that are of less concern to the more mature IOM membership.

The conduct of these programs also raises some interesting management issues for the IOM. Nearly 400 fellows have graduated from the two programs and most will not achieve IOM membership. What is the IOM 's responsibility to the alumni? How best can it benefit from the diverse set of disciplines and professional experiences the alumni represent?

The RWJ Health Policy Fellowship Program raises an additional question, namely, how to keep the necessarily partisan activities of the congressional offices in which the fellows work separate from the explicitly nonpartisan IOM? To date, maintaining that separation has been accomplished by dint of a nonpartisan fellows-selection process and skillful program management by Ms. Lewin.

Philanthropic foundations make grants in fulfillment of their mission. Pew's mission is “to encourage individual development and personal achievement, cross-disciplinary problem solving, and innovative, practical approaches to meeting the changing needs of a global community.” It gives grants in six major program areas, one of which is health and human services. By contrast, the RWJ Foundation restricts its focus to health, as defined by its mission of “improving the health and health care of all Americans.”

As foundation staffs and their governing boards ponder how best to use the funds with which they are entrusted, they can choose among a variety of grantmaking strategies, one of which is the training of young people. It might be assumed that fellowship programs are quite popular among foundations; after all, what could be better than investing in the future, and what institutions are as well positioned to take the long view, as contrasted with the shorter time horizons of government and private industry?

In fact, fellowship programs are not as popular among foundations as one might think. A major reason is their cost. Consider, for example, the RWJ Foundation's Clinical Scholars Program, its oldest and best-known fellowship program. Including the scholar stipends, fringe benefits, faculty costs, and travel, it costs about $225,000 per scholar for this 2-year program. Costs per health policy fellow are less, about $125,000, but this is only a 1-year program. When you multiply the costs per individual by the number of such slots needed to achieve critical program mass, it is clear that fellowship programs are very expensive—and necessarily long term. Costs can be reduced by selecting less expensive targets than physicians and other health professionals, by requiring sponsoring institutions to pay a higher proportion of the fellow's salary (e.g., an RWJ fellow receives a foundation stipend of $50,000, with the sponsoring health center adding a separate contribution), or by reducing educational and administrative support. Each of these reductions, of course, would carry program implications.

In addition to concerns about costs, fellowship programs have another disadvantage when competing for foundation support. Compared with demonstration programs, media support, research projects, policy analysis, public opinion polls, or even facility construction, fellowships are relatively invisible to foundation staff and trustees. The payoffs for the other programs are more immediate. It is easier to judge the quality of research and demonstration programs, the impact of a television documentary, or the grandeur of a college library than it is to assess the impact of a fellowship program.

Notwithstanding these handicaps of expense and relative invisibility, the RWJ and Pew Foundations continue to support fellowship programs, stimulated by the conviction that their impact is enduring and that foundations are almost uniquely positioned to invest in such long-range projects. But, as with

all sponsored projects, decisions have to be made about their duration. Both programs were evaluated by outside experts, as reported by Ms. Lewin, to aid in this decision. The RWJ Foundation recently decided to renew its program for at least an additional 5 years. Alhough Pew is discontinuing its health policy program, it will continue other fellowship activities, such as the Pew Latin American Fellows Program.

Until recently, health policy analysis was not a major concern of most academic health centers. However, the failure of national health care reform legislation in the last Congress, the contemplated budgetary changes in Medicare and Medicaid, shrinking federal dollars for health and entitlement programs, and the flurry of market-driven changes in how local health care is financed and delivered have clearly stimulated an interest in this subject.

Early in the course of the RWJ program, foundation leaders hoped that fellows would return from their year in Washington to assume roles as institutional change agents. More often, however, the returning fellows found it difficult to apply their new knowledge and skills in their old academic homes. The experience in Washington had changed them, but their old institution was still the same. Some returned to their former roles and viewed the year in Washington as a fascinating experience that permitted sporadic local and national applications. Others were stricken with Potomac Fever and looked for career shifts that brought them closer to policy work and to Washington. Very few found meaningful policy roles within their home institutions. As a result of these realities, the foundation changed its expectations about the fellowship's impact on sponsoring institutions.

I don't know whether Pew's staff had similar ideas about improving the profile of health policy research at its training sites. Until recently, the steady growth of available funds at the federal Agency for Health Care Policy and Research seemed to favor such growth, but the likely cutbacks planned this year may discourage investment in health policy programs. Certainly, the Pew program can claim success in having trained an impressive number of skilled health policy researchers.

For the 5 years that I have been president of the RWJ Foundation, I have met periodically with our fellows, both at formal presentations and at occasions when we could let our hair down and talk candidly about their brief

passage on the ship of state. Each cohort encounters a different Washington atmosphere. In 1995, for example, the dominant themes have been changes in the Medicare and Medicaid budgets, block grants, and devolution of decision-making to the states. The previous 2 years focused on the prospect of national health care reform. Despite the cyclical variations, there have been several constants. For one thing, all the fellows have been impressed with the dedication and professionalism of the congressional staff—a refreshing commentary in this era of disillusionment with government. There also has been exhilaration about working in Congress, so much so that most have found it traumatic to end the experience, despite the typically grueling schedules. Indeed, many have sought opportunities to remain in the Washington health policy process. Over the past several years many have been surprised at the extent to which party politics drives policy debates. Whether this perception reflects political naiveté or a shift in the prevailing political climate is an important question; I suspect it is the latter.

The Pew fellows are not concentrated in one location, and I have had much less contact with them. In contrast to the RWJ fellows, who have acquired new skills in midcareer, most Pew fellows are entering the health policy arena for the first time. They are entering a field in which economics has been the dominant intellectual discipline. For those fellows who represent other disciplines, the extent to which they accept or challenge the dominant economic paradigm must be a major intellectual issue. The wide range of professional activities represented by the Pew fellows testifies to the flexibility of a career in health policy analysis. Because of their multidisciplinary and heterogeneous backgrounds, the issue of career direction must preoccupy many. Given the current and future uncertainty of federal health policy research support, one would also expect that more of the fellows will migrate into positions in corporations and nonprofit organizations, rather than academia.

In summary, fellowship programs have been an important activity during the IOM's first quarter-century. Though certainly not the Institute 's signature activity, managing these two programs adds an invigorating supplement to its core programs. To what extent this role is maintained will depend on the continued commitment of the three involved institutional partners. Still, as long as our nation's desire for health care exceeds our willingness to pay for it, there will continue to be a need for the kind of well-trained, seasoned health policy analysts that these partnerships have produced for more than two decades.

Finally, a word of admiration and gratitude: Marion Ein Lewin's concise description understates her own critical role in providing the personal glue that holds together these two labor-intensive fellowship programs. Highly trained professionals who chose unusual career paths —such as the interdisciplinary experiences of health policy fellowships —commonly suffer pangs

of doubt and insecurity. Tensions between breadth and depth, rigor and relevance, and short- versus long-term impact gnaw at many fellows, and they frequently wrestle with issues of career stability and direction. Without Marion's wise and comforting counsel, these programs would not have fared so well.