To Improve Human Health A History of the Institute of Medicine (1998) / Chapter Skim
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5 Expansion of the Institute of Medicine
5 Expansion of the Institute of Medicine
Pages 179-210
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From page 179... ...
It was nonetheless the case that the TOM rebounded from the crisis of the Sproull report under the leadership of Samuel Thier. In a short time, Thier restored the confidence of foundations in the Institute of Medicine, leading to a more stable pattern of financing and ending the yearly struggle to make ends meet.
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From page 180... ...
Under his leadership, he promised, the TOM would strive to complete its studies more quickly, with the goal of cutting in half the time necessary to complete studies. Using the TOM's convening power, he planned to bring together the parties interested in drug development and health technology assessment in order to facilitate communication among participants in these particular fields.
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From page 181... ...
Under his and William Kelley~s leadership, the board had established the subspecialty of geriatrics. In addition, Thier held many appointments related to his academic position, such as chief of medical service at the Yale-New Haven Hospital and member of the editorial board of the New England Journal of Medicines When Thier presided over his first Council meeting on November 1S, 1985, it immediately became apparent that the TOM would no longer be, in the words of a veteran TOM member, "Sleepy Hollow." Thier cut through much of the talk that tended to slow the organization down.
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From page 182... ...
"The conditions of the grant are fully acceptable to us," Thier replied, noting tha~there was "no organization to which the Institute is as deeply indebted for its continuing support as it is to the Robert Wood Johnson Foundation."8 The TOM used the RW] grant as the basis for a capital campaign announced in March 1987.
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From page 183... ...
Despite these inevitable disagreements, the fact is that the TOM enjoyed unprecedented success in its outreach to foundations during the presidency of Samuel Thier. One factor in this success was the surge in the stock market and the economic boom that occurred in the mid- to late 1980s.
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From page 184... ...
Report Dissemination and Expansion of the Institute One of the items on which Thier spent the TOM's newfound money was the dissemination of TOM reports. From the day he took over as TOM president, he vowed to make an effort to distribute TOM reports in an organized fashion, beginning with the original proposal and extending through the evaluation of the final report's impact.~4 "Dissemination is our current buzz word," said communications director Wallace Waterfall in 1987,~5 referring to such things as a videotape of the symposium on the medical effects of nuclear war that the TOM prepared for distribution to universities and the special efforts that the lOM made to publicize its study on prenatal care.
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From page 185... ...
In the summer of 198S, Sarah Brown, the staff study director, testified before both the House Committee on Government Operations and the Senate Finance Committee.~7 This sort of attention to dissemination became a key part of Thier's plan to improve the performance and influence of the TOM.M one document of the period stated, "The recommendations of a study can only be regarded as disseminated when they are acted upon by the health enterprise." Other components of the TOM's "new directions" included better targeting of health policy problems as they developed, greater versatility in responding to problems, and closer involvement of members in the creation of the program plan and the execution of TOM studies. Increased funds and more attention to dissemination brought positive results in the form of increased prominence within the National Academy of Sciences, growth of the TOM staff, and expansion of the TOM's organizational responsibilities.
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From page 186... ...
Unlike the other parts of the Institute of Medicine, the Medical Follow-Up Agency engaged in the conduct of original research, often with statisticians and epidemiologists on the staff acting in collaboration with clinical investigators and epidemiologists from academic medical centers.22 The Food and Nutrition Board was a larger and more complex undertaking. Started during the Second World War, it addressed issues of critical importance that pertained to the adequacy and safety of the nation's food supply as well as matters that related to proper diet and nutrition.
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From page 187... ...
Expansion of the Institute of Medicine ~7
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From page 188... ...
The idea behind this effort, an experiment that soon evolved into a regular activity of the Institute's Board on Health Sciences Policy, was to provide "regular meetings in a nonadversarial environment for representatives from government, industry, and academia to discuss pharmaceuticals." Recognizing the value of such an institution, federal agencies concerned with drug development such as the Food and Drug Administration, professional organizations such as the American Medical Association, and private trade associations such as the Pharmaceutical Manufacturers Association all contributed to the forum's upkeep. The Forum on Drug Development, as the entity ultimately became known, involved little of the internal clearances and other hindrances that often delayed TOM initiatives.
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From page 189... ...
. hindered the work of the Council," Enriqueta Bond of the IOM staff explained.29 In its relatively short life, the 16-person council, chaired by William Hubbard, the former head of the Upjohn Company, and cochaired by Jeremiah Barondess, a professor of clinical medicine at Cornell University Medical College and later president of the New York Academy of Medicine, studied aspects of the use of technology in health care.
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From page 190... ...
The key factor was that the absence of a financial burden gave the TOM a new freedom to set its own agenda. Samuel Thier feared that the National Research Council, with its ethos of service, had become a "job shop" that responded to all requests for assistance.
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From page 191... ...
By the end of the year, it tract raised more than $23.2 million from its capital campaign, including $~.9 million in endowment.35 i7VLereas before the TOM Council had spent an inordinate amount of time trying to come up with a financial development strategy, it now thought of ways to control the consequences of growth. At one point, for example, Shier suggested the development of a computer program that would enable one division to track the activities of another through the use of key words.36 Samuel Thier credited his staff members with making much of the growth possible.
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From page 192... ...
Even with the influx of money and the concentration on report dissemination, only a few studies issued by the TOM in the late 1980s or early 1990s, such as those on prenatal care and on nutritional guidelines, captured the attention or imagination of the general public. Instead, the organization continued to speak out on a wide variety of medical issues and to influence, in a limited way, the direction of public policy.
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From page 193... ...
In this manner, the Institute of Medicine came to be the author, if such a thing were possible in the collaborative world of Congress, of the National Vaccine Program and the National Childhood Injury Act of 1986 that were contained in the law.39 The report on vaccine innovation and supply illustrated nearly all of the elements of Samuel Thier's strategy to increase the TOM's effectiveness. First, the TOM paid a great deal of attention to the process of dissemination, making sure the report came to the attention of key policymakers and journalists.
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From page 194... ...
It was the sort of thing that the TOM listed in its annual reports under headings such as "making a difference" or "impact."40 Not everything worked so well, as TOM's experience with the Committee on Health Objectives for the Year 2000 demonstrated. This project was larger, more diffuse, less well-suited to the National Academy of Science's ethos of scientific investigation, and much closer to the surface of partisan politics than others that the TOM undertook.
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From page 195... ...
In Birmingham, Alabama, an academic physician from the University of Tennessee testified on the subject of breast cancer, a disease that he characterized as "common, curable, and easily detectable." Despite this fact, people continued to die of breast cancer, most often because of a delay in diagnosis that was the result of "negative feelings about health care facilities, avoidance and denial and societal conditions that lead to a fatalism about the disease." A physician from Nashville, Tennessee, said that poor people delayed seeking treatment for high blood pressure because of financial barriers and also because of a "culturally determined belief that favors reliance on family, friends, and spiritualists over medical professionals." A member of the Washington State House of Representatives told the TOM study group in Seattle that the number one issue was health care financing. "Legislators," he testified, "see health dollars as a kind of pac man (a nodular viden Acme Of t.h" norms =~tin~ ~r~r;^l~a trite Four ~ _ A_ _ ,1~ _ =~ , ~ __= ,~ ^ ^~ J .
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From page 196... ...
Saying that this arrangement violated National Academy of Sciences rules, Samuel Thier wanted the TOM to drop out as a cosponsor. To navigate around these difficulties, the Public Health Service and the Institute of Medicine negotiated an agreement under which the Year 2000 Health Objectives Consortium, created and managed by the IOM, became a cosponsor with the United Way.
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From page 197... ...
~ , ~ ~ A Ull~b ~ Chance of public neaten constituted an important mission of government at all levels and that public health officials should have the advantage of expert knowledge derived from fields such as epidemiology and biostatistics rather than being forced to make decisions on the "basis of competition, bargaining and influence." In other words, these people, experts themselves, believed that professional expertise should inform politics. The report sought a reaffirmation of the nation's traditional public health mission.
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From page 198... ...
In keeping with the TOM's modern sense of style, the report summary came bound in an attractive booklet with a colorful cover, whose sheer cheerfulness tended to counteract the utilitarian nature of the subject under discussion. For harried readers who lacked the time for the summary, the essence of the report could be gleaned by reading the text box on page six that listed the report's seven major recommendations.
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From page 199... ...
At the heart of these objections was the concern of NAS President Frank Press that the committee had gone beyond the boundaries set by the evidence and strayed into areas not contained in the congressional mandate. Bruce Vladeck, chairman of the study group who later became the head of the Health Care Financing Administration during the Clinton presidency, told the committee that he saw himself as its advocate in the review process.50 After repeated delays and substantial NAS editing of the report, Vladeck complained that the edited report lacked "emphasis, strength, and passion." To counteract this impression, he drafted a
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From page 200... ...
When the Social Security Administration responded by removing many people from the rolls in the early 1980s, Congress shifted direction and expressed concern for people taken off the rolls in the midst of a severe recession. Congress passed a law in 1984 that made it more difficult to remove a person from the disability rolls.
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From page 201... ...
In 1990, for example, one of the cross-cutting themes of the Institute's work was "the role, education and supply of health professionals." In support of this theme, the TOM released a report on financing the graduate medical education (GME) of primary care physicians in ambulatory settings.
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From page 202... ...
As the report noted, physicians in primary care practice responded to community health needs in settings that ranged from solo practice to HMOs; the hospital was no longer a suitable principal focus for the GME experience of such physicians. The committee concluded that "the care provided by future generations of primary care physicians would be enhanced if the GME experience placed greater emphasis on training in primary care outpatient settings." Although the report's effect on public policy was scant, it helped call attention to the need to match the educational system with the realities of medical practice.
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From page 203... ...
If anything, the TOM moved more cautiously in the Thier years than before, in part because of the realization that its actions had real policy consequences and in part because of a new financial independence that made it less dependent on external funders. When, for example, the TOM convened a group to consider what projects, if any, the organization should pursue in the area of medically assisted technology, Thier warned that it should not become enmeshed in the "sociopolitical arguments" that had arisen over medically assisted conception.
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From page 204... ...
Even with the transfer of new agencies from the NRC to the TOM, the boundary between these two parts of the Academy complex was unstable. In November 1989, Samuel Thier complained, as had his predecessors, that the overlap was "not well controlled" and that such topics as animal research, radiation effects research, and environmental studies and toxicology led to duplication and competition between the Institute of Medicine and the Commission on Life Sciences.
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From page 205... ...
When the Board on Medicine started, it included individuals such as Adam Yarmolinsky, who were distinguished in their own fields, lacked direct experience in medicine, and became quite interested in medical affairs in large part because of their involvement with the TOM.
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From page 206... ...
In 1989, Samuel Thier noted with pride that Dr. Louis Sullivan had been nominated by President-elect George Bush to serve as Secretary of Health and Human Services.
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From page 207... ...
9. "Institute of Medicine, Aiming for Endowment, Gets Johnson Foundation Pledge," IOM Press Release, March 31, 1987, IOM Records; IOM Council Meeting, Minutes, November 17-18, 1986, IOM Records.
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From page 208... ...
34. IOM Council Meeting, Minutes, November 16-17, 1987, IOM Records; Samuel Thier to IOM Members, December 9, 1987, Yordy Files, Accession 91-051, IOM Records.
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From page 209... ...
51. IOM Council Meeting, Minutes, January 25-26, 1988, and July 2122, 1988, IOM Records; Bruce Vladeck to Members of the Committee on Health Care for Homeless People, Homelessness Study Records, Accession 90047-4, IOM Records.
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From page 210... ...
60. IOM Council Meeting, Minutes, January 26, 1988, IOM Records.
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