To Improve Human Health A History of the Institute of Medicine (1998) / Chapter Skim
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2 The Institute of Medicine Begins Operations
2 The Institute of Medicine Begins Operations
Pages 50-94
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From page 50... ...
We have never felt that we would become, at least in the first years, an opinion maker at the level of the individual citizen."2 As Bulger indicated, the Institute of Medicine attracted little national attention during its first five years of operations. This was because its work did not directly engage the questions that animated the public, such as the passage of national health insurance, nor did its leaders seek to become political celebrities who testified often before Congress.
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From page 51... ...
Neither of these presidents served for a long time. John Hogness spent three years in office before leaving to become president of the University of Washington; Donald Fredrickson stayed at the TOM for less than a year, much of it spent in distracting and ultimately successful negotiations with federal officials over whether he would become the head of the National Institutes of Health (NTH)
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From page 52... ...
Then, in 1965, he arrived at Stanford to become dean of the medical school. Five years later, Glaser accepted a job as vice president of the Commonwealth Fund, which enabled him to make occasional trips from New York to Washington to handle TOM business on a part-time basis.3 Glaser chaired what was known as the Initial Membership Committee.
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From page 53... ...
Ever since the formation of an Institute of Medicine had become a real possibility, Philip Handler had received a stream of letters from organizations arguing that they deserved representation in the TOM. Psychiatrists, pharmacists, toxicologists, veterinarians, dieticians, and rehabilitation doctors all wrote to Handier.
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From page 54... ...
Glaser even admitted that in the absence of these academic criteria, the selection process for practicing physicians was less rigorous than for other members. Identifying physicians engaged in the private practice of medicine who had national reputations proved a difficult task.
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From page 55... ...
On January 20, 1971, Glaser reported to Philip Handier on a meeting with John Hogness, former dean of the Medical School at the University of Washington and current director of the university's Health Sciences Center. "l got the feeling," Glaser noted, "that John is extremely interested and that the chances are very good that he will be interested in taking it on." Two months later, Handier made a formal offer to Hogness to serve a f~ve-year term beginning on July I, 1971.
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From page 56... ...
Not only had he been in private practice, he had served as secretary-treasurer of the local medical society. Not only had he done research in endocrinology, he had also chaired the Board of Health Sciences at the University of Washington and come to know the members of other health professions.
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From page 57... ...
topflight training at the nation's best medical schools, including the University of Chicago and Columbia, before coming to Seattle in 1950 as a chief resident at King County Hospital, a teaching hospital for the newly formed University of Washington School of Medicine.~4 "At last we have a pope," one waggish doctor remarked on learning of Hogness's selection.~5 Even as Hogness spoke ex cathecira of the TOM and its mission, he realized that the new organization was far from becoming the "established church" in its field. The TOM resembled a movie set with a glossy front and the illusion of depth.
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From page 58... ...
Yordy, who would remain in positions of authority at the TOM from the era of John Hogness until the era of Ken Shine, soon became indispensable not only to the Program Committee but to Hogness and Bulger as well. As for other committee assignments, Dr.
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From page 59... ...
Members required a forum in which they could meet one another, discuss the TOM's program, and become a part of the organization. Hogness set the meeting date for the middle of November and put Samuel Nabrit, Irvine Page, and Eugene Stead in charge of coming up with a program.
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From page 60... ...
As several TOM members noted in March, "there is the mistaken belief that equates a separate agency with curing cancer."27 Philip Handier, whose own background was in biological research that took place in a medical school, felt strongly enough about the issue to write Kennedy and davits a letter advising against the National Cancer Authority. Handier urged the TOM to move on the issue, but with the organization still so new and eager not to make a mistake in handling its first big political issue, TOM leaders hesitated to make a public stand.28 When the political action shifted from the Senate to the House, John Hogness received a request to testify before Congressman Paul Rogers (D-Fla.)
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From page 61... ...
The opportunity came in 1972 when the NAS received a request from the Office of Science and Technology in the White House to review the National Cancer Program for the National Cancer Institute (NCI)
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From page 62... ...
The sticking point came over whether the NAS Council would also have to review Thomas's report. Technically, it had such a right, but it often waived that right for something already reviewed by another part of the organization.
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From page 63... ...
The Institute of Medicine inherited the entitlement study from the Board on Medicine. Board members had recognized national health insurance as one of the most important concerns of health care policy and wanted to do something about it.
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From page 64... ...
It reflected the sense in the early 1970s that passage of national health insurance was inevitable, and therefore the more rational, dispassionate planning that preceded it, the better. The study was part and parcel of the Board on Medicine's outlook that it should engage broad social questions.
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From page 65... ...
Rashi Fein, an academic economist and avowed partisan of national health insurance, was concerned that planning for national health insurance would be suspended for the life of the study, thereby delaying passage of the measure.4i These comments revealed that the project had begun to encounter the polarized politics of national health insurance.42 Nonetheless, the NAS Council joined the TOM Executive Committee in approving it. Just as this proposal was ready for public distribution, the IOM's Program Committee began to meet.
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From page 66... ...
Hogness knew it would be difficult to obtain funding for a broad study of health insurance because the administration had submitted a health insurance proposal of its own. The National Center for Health Services Research and Development, a creature of the Great Society, tract long since fallen out of favor with the Department of Health, Education, and Welfare.
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From page 67... ...
The idea captured the imagination of the TOM Council and won the approval of the Program Committee, the Council, and NAS authorities. In February 1974, John Hogness invited Dr.
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From page 68... ...
This made fund-raising a timeconsuming, frustrating activity that continued throughout the project. When the project began, no one knew if the money would hold un lone enough for it to he ~.omnl~t.~H 52 , ~ _ =~ r-~~~ Unlike the entitlement and health contrast studies, the steering committee for the abortion study made no effort to perform original research.
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From page 69... ...
One of the first came about as a result of a provision in the Social Security Amendments of 1972 that awarded health insurance coverage through Medicare to people with end-stage renal disease (ESRD)
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From page 70... ...
study to function in a manner similar to the categorical approach report. It would be a moclest effort that would produce what John Hogness called a "background paper on health maintenance organizations." Hogness discovered, however, just how hard it was for the IOM to stay current with breaking events.
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From page 71... ...
In November 1971, John Hogness received a letter from Merlin K DuVal, Assistant Secretary for Health and Scientific Affairs at the Department of Health, Education, and Welfare, mentioning the fact that Congress was about to pass the Comprehensive Health Manpower Training Act of 1971.
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From page 72... ...
He had met her during his service on the HEW Secretaries Task Force on Medicaid and had come to admire both her technical skills and her Washington sawy. Hanft was, in fact, a distinguished figure in health services research who, among other things, enjoyed a close working relationship with HEW Secretary Elliott Richardson and had played a key role in designing the Nixon administration's health insurance proposal.
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From page 73... ...
It included a great deal of data and even a technical appendix. It also contained a series of broad philosophical recommendations, for example, that "health professional schools be regarded as a national resource requiring Federal support." The group endorsed a capitation grant program as "an appropriate Federal undertaking to provide a stable source of financial support for health professional schools" and recommended that capitation grants ranging between 25 and 40 percent of net educational expenditures "would contribute to the financial stability of the schools and would be an appropriate complement to other sources of income."66 When it came time to brief the Subcommittee on Health and the Environment of the House Interstate and Foreign Commerce Committee, Hanft, rather than Julius Richmond, did the talking.
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From page 74... ...
In the end, however, the Institute of Medicine contained a core constituency of faculty members and administrators from academic medical centers. On the 10-person steering committee, only Eli Ginzberg, a Columbia professor, and Morton Miller, executive vice president and chief actuary of the Equitable Life Assurance Society, were not directly involved with medical education.
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From page 75... ...
The Program Committee under the direction of Irving London and with the staff support of Karl Yordy held frequent meetings not only to consider specific proposals but also to produce a general framework for the TOM's work. As a first cut, the committee divided the proposals into 10 general categories.
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From page 76... ...
Roger Bulger conceded that the categories were rather loose but thought it important just "to get started." Even the Program Committee did not regard the categories as fixed. After consulting with members, for example, the committee realized that "government regulations and health administration" (category 9)
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From page 77... ...
He estimated that the TOM would need at least $700,000 just to sustain its central activities including staff salaries and money to pay the travel expenses of the members of the TOM Council and the TOM Program Committee.76 Although those who served on TOM committees did so without compensation, they still generated bills for transportation and lodging. Looking to the foundation community to support the TOM, Hogness made the rounds of foundations that took an interest in medicine and medical policy.
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From page 78... ...
Robert d. Glaser, who worked at the Commonwealth Fund, reminded John Hogness that during the Board on Medicine days, Irvine Page had gone to see a member of the Mellon family and asked for "a massive amount of money to set up an independent academy." Glaser urged Hogness to visit George Taber, director of the Richard King Mellon Trust, and tell him that the TOM was the direct outgrowth of Page's efforts.
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From page 79... ...
It therefore mattered when a high official of the Commonwealth Fund criticized the TOM for taking a "shotgun" approach to health policy issues or an official from the Kellogg Foundation said that the TOM did not do enough to disseminate the results of its stuclies.83 There was, in other words, no free lunch. It also took considerable industry to "scrounge up" the lunch.
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From page 80... ...
The elections between 1972 and 1976 were typical in the way that so many members participated and so many were discontented with the results. In 1972, the members made 160 formal nominations for 60 available positions, and the Membership Committee reduced the number to 84.
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From page 81... ...
It began with a $710,000 grant from the foundation to the TOM, intended to "offset severe shortages of faculty members in the nation's academic medical centers who are specifically qualified for research, teaching, and service in the complex field of health policy."90 The idea was to bring a small number of academic physicians and other health professionals to
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From page 82... ...
Indeed, John Hogness later claimed that Handier had never wanted the Institute to be created in the first place, but his other priorities prevented a major confrontation. These consisted of
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From page 83... ...
. HandIer's relationship with Clarence Linder, the NAE president, was far worse than his relationship with John Hogness.
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From page 84... ...
A search committee headed by Walsh McDermott moved quickly to select a successor. The committee chose Donald Fredrickson, who had the distinction of being a member of both the Institute of Medicine and the National Academy of Sciences.96 Two years younger than Hogness, Fredrickson had followed a different route in his career.
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From page 85... ...
The members' meeting in the spring of 1974 served as an inauguration of sorts for Donald Fredrickson. He spoke of bridging the worlds of science and medical practice, arguing that the lOM's commitment was to "lend the scientific method to the direction of a whole social movement." Noting that the TOM's success rested upon the "essence, not merely the appearance, of nonpartisan objectivity," he predicted that the same sort of satisfaction he had found in the laboratory could also be found at the Institute of Medicine.
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From page 86... ...
He realized that although changing presidents twice in four years created great potential for harm, he was confident that the TOM would "survive its president." He owed his confidence to his faith that Julius Richmond and Roger Bulger would preside effectively over the Institute during the transition period. He alto took solace in the fact that the Robert Wood Johnson and Kellogg Foundations had renewed their core grants to the TOM and that the TOM would be able to maintain a budget of from $3.5 million to $4 million in fiscal year 1976.98 "In retrospect the time you have spent with us now seems to have been extraordinarily short," Handier wrote to Fredrickson.99 Indeed, Fredrickson had only a few months to concentrate on the TOM.
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From page 87... ...
let the world know of its accomplishments. As a way to overcome some of these problems, John Hogness had "utilized the development of a staff as a combination of acquiring expertise anct analytic abilities with extending the points of contact for the Institute throughout the health establishment." The members of the staff complemented one another.
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From page 88... ...
8. Robert Glaser to Philip Handler, April 16, 1971, IOM Membership, 1971, NAS Records.
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From page 89... ...
Glaser to Philip Handler, January 20, 1971; Handler to Dr. John Hogness, March 24, 1971; and NAS Press Release, March 30, 1971, all in Institute of Medicine, Administrative, President, 1971, NAS Records.
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From page 90... ...
33. John Hogness to Philip Handler, November 29, 1972, in Materials for IOM Council Meeting, January 18, 1973, IOM Records.
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From page 91... ...
63. IOM Council Meeting, Minutes, March 16, 1972, IOM Records; John Hogness oral interview; Oral interview with Ruth Hnnft, June 10, 1997, Washington, D.C.; Testimony of Roger J
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From page 92... ...
79. John Hogness to David Rogers, June 20, 1973, Funding Files 19721981, Accession 90-074, IOM Records.
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From page 93... ...
87. John Hogness to Irvine Page, September 19, 1972, IOM Membership, 1972, NAS Records; Philip Handler to Hogness, June 13, 1973, and David Mechanic to Roger Bulger, both in Materials for IOM Council Meeting, July 1974, IOM Records; IOM Council Meeting, Minutes, March 20, 1975, IOM Records.
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From page 94... ...
Unger to Donald Fredrickson, Julius Richmond, and Nathan Start, May 12, 1975, attachment to IOM Council Meeting, Minutes, May 15, 1971, IOM Records.
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