|
Items in cart [0] |
Questions? Call 888-624-8373 |
| Copyright © 2010. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page R1
HHS in the 21st Century: Charting a New Course for a Healthier America
HHS IN THE 21st CENTURY
CHARTING A NEW COURSE FOR A HEALTHIER AMERICA
Committee on Improving the Organization of the U.S. Department of Health and Human Services (HHS) to Advance the Health of Our Population
Leonard D. Schaeffer, Andrea M. Schultz, and Judith A. Salerno, Editors
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
OCR for page R2
HHS in the 21st Century: Charting a New Course for a Healthier America
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
Support for this project was provided by the National Academies. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
Library of Congress Cataloging-in-Publication Data
HHS in the 21st century : charting a new course for a healthier America / Committee on Improving the Organization of the U.S. Department of Health and Human Services (HHS) to Advance the Health of Our Population ; Leonard D. Schaeffer, Andrea M. Schultz, and Judith A. Salerno, editors.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-309-13770-6 (hardcover)
1. United States. Dept. of Health and Human Services. 2. Public health—United States. 3. Medical policy—United States. I. Schaeffer, Leonard D. II. Schultz, Andrea M. III. Salerno, Judith A. IV. Institute of Medicine (U.S.). Committee on Improving the Organization of the U.S. Department of Health and Human Services (HHS) to Advance the Health of Our Population.
[DNLM: 1. United States. Dept. of Health and Human Services. 2. Health Services Administration—United States. 3. Health Policy—United States. 4. Organizational Objectives—United States. 5. Organizational Policy—United States. 6. Program Evaluation—United States. 7. United States Government Agencies—United States. W 84 AA1 H589 2009]
RA11.H47 2009
362.1—dc22
2009005930
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2009 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: IOM (Institute of Medicine). 2009. HHS in the 21st century: Charting a new course for a healthier America. Washington, DC: The National Academies Press.
OCR for page R3
HHS in the 21st Century: Charting a New Course for a Healthier America
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
OCR for page R4
HHS in the 21st Century: Charting a New Course for a Healthier America
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
OCR for page R5
HHS in the 21st Century: Charting a New Course for a Healthier America
COMMITTEE ON IMPROVING THE ORGANIZATION OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) TO ADVANCE THE HEALTH OF OUR POPULATION
LEONARD D. SCHAEFFER (Chair), Judge Robert Maclay Widney Professor,
University of Southern California
DAVID W. BEIER, Senior Vice President of Global Government and Corporate Affairs,
Amgen
KATHLEEN BUTO, Vice President,
Health Policy, Johnson & Johnson
MOLLY JOEL COYE, Founder and CEO,
Health Technology Center
ROBERT GRAHAM, Professor of Family Medicine, Robert and Myfanwy Smith Chair,
Department of Family Medicine, University of Cincinnati College of Medicine
MARK B. McCLELLAN, Senior Fellow,
Economic Studies, Brookings Institution
STANLEY B. PRUSINER, Professor of Neurology, Director,
Institute for Neurodegenerative Diseases, University of California, San Francisco
DONNA E. SHALALA, President,
University of Miami
STEPHEN M. SHORTELL, Blue Cross of California Distinguished Professor of Health Policy and Management; Professor of Organization Behavior; Dean,
School of Public Health, University of California, Berkeley
SUSANNE A. STOIBER, Consultant,
Stoiber Health Policy, LLC
LOUIS W. SULLIVAN, President Emeritus,
Morehouse School of Medicine
DAVID N. SUNDWALL, Executive Director,
Utah Department of Health
GAIL L. WARDEN, President Emeritus,
Henry Ford Health System
MYRL WEINBERG, President,
National Health Council
CATHERINE E. WOTEKI, Global Director of Scientific Affairs,
Mars, Inc.
Study Staff
JUDITH A. SALERNO, Executive Officer
ANDREA M. SCHULTZ, Associate Program Officer
KATHARINE BOTHNER, Research Associate
AMY PACKMAN, Administrative Assistant
JUDITH L. ESTEP, Program Associate
OCR for page R6
HHS in the 21st Century: Charting a New Course for a Healthier America
Institute of Medicine Consultants
DARREL J. GRINSTEAD,
Hogan and Hartson, LLP
BOB KOCHER,
McKinsey and Company
PAUL C. LIGHT,
Robert F. Wagner School of Public Service, New York University
NEIL E. WEISFELD,
NEW Associates, LLC
VICTORIA D. WEISFELD,
NEW Associates, LLC
OCR for page R7
HHS in the 21st Century: Charting a New Course for a Healthier America
Independent Report Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Alex M. Azar II, Eli Lilly and Company
Jo Ivey Boufford, New York Academy of Medicine
David Brailer, Health Evolution Partners
Robin H. Carle, The Sullivan Alliance, Joint Center for Political and Economic Studies
Jack C. Ebeler, Ebeler Consulting
Arthur L. Kellermann, Department of Emergency Medicine, Emory University School of Medicine
Howard K. Koh, Division of Public Health Practice, Harvard School of Public Health
Judith R. Lave, Pennsylvania Medicaid Policy Center, Graduate School of Public Health, University of Pittsburgh
Lawrence S. Lewin, Executive Consultant
Philip A. Pizzo, Stanford University School of Medicine
Beryl A. Radin, Scholar in Residence, Department of Public Administration and Policy, American University School of Public Affairs
OCR for page R8
HHS in the 21st Century: Charting a New Course for a Healthier America
David Satcher, Satcher Health Leadership Institute Initiative, Morehouse College School of Medicine
Michael R. Taylor, School of Public Health and Health Services, The George Washington University
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Gilbert Omenn, Center for Computational Medicine and Biology, University of Michigan Medical School, and Floyd E. Bloom, Department of Molecular and Integrative Neuroscience, Professor Emeritus, The Scripps Research Institute. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
OCR for page R9
HHS in the 21st Century: Charting a New Course for a Healthier America
Foreword
“Form follows function” is a principle of architectural design and a truism of biology. It is not, however, an imperative of human organizations, and certainly not of government agencies. Rather, over a period of years, new responsibilities may be layered onto an existing agency, and old responsibilities removed, without a responsive realignment of positions, procedures, and structures. From time to time, it is worth taking a step back from the current way of conducting government business, examine practices in light of contemporary responsibilities, and seek ways to enable government to fulfill its obligations more successfully and efficiently.
Prompted by a letter from Representatives Henry A. Waxman and Tom Davis, respectively the chair and ranking minority member of the House Committee on Oversight and Government Reform, the Institute of Medicine undertook just such an assessment of the Department of Health and Human Services. This large and diverse department profoundly affects the lives of Americans every day. To advise on how the department’s work can be improved, the IOM assembled an able and experienced committee, admirably led by its chair, Leonard D. Schaeffer. With an intensive effort, outstanding contributions from a select group of consulting experts, and superb support by staff member Andrea Schultz and IOM Executive Officer Judy Salerno, the committee prepared the following report and recommendations. We offer it in the hope that it will help a new secretary, Congress, and administration to serve the public and advance the health and well-being of the American people.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
OCR for page R10
HHS in the 21st Century: Charting a New Course for a Healthier America
This page intentionally left blank.
OCR for page R11
HHS in the 21st Century: Charting a New Course for a Healthier America
Acknowledgments
This report is the result of the contributions of many individuals who provided their expertise and shared their time throughout the study. The committee wishes to acknowledge those whose contributions energized our deliberations and enhanced the quality of our report.
We would first like to thank the National Research Council Presidents’ Circle, whose generous funding made this study possible.
Invaluable information was provided by the authors of two commissioned papers, Darrel Grinstead and Paul Light. During our meeting, Bob Kocher provided his expertise and insight. Our deliberations were captured and organized into the text of this report by Neil and Vicki Weisfeld. Throughout, Dana McMurtry provided research assistance to the committee chair.
The committee is greatly appreciative of the study staff for their tireless work. We would like to give special thanks to Judith Salerno for her oversight and guidance and Andrea Schultz for her daily direction and dedication to the study. Thanks also go to Katharine Bothner for her excellent research assistance, Amy Packman and Judy Estep for their administrative support, and Florence Poillon and Mark Goodin for copyediting the final report.
Finally, the committee is especially grateful to the numerous additional IOM staff members who contributed to the study process, production, and dissemination of the report: Anton Bandy, Clyde Behney, Christie Bell, Porter Coggeshall, Bronwyn Schrecker Jamrok, Jim Jensen, William McLeod, Abbey Meltzer, Linda Meyers, Maria Oria, Christine Stencel, Lauren Tobias, Jackie Turner, and Jordan Wyndelts.
OCR for page R12
HHS in the 21st Century: Charting a New Course for a Healthier America
This page intentionally left blank.
OCR for page R13
HHS in the 21st Century: Charting a New Course for a Healthier America
Preface
This report is the Institute of Medicine’s (IOM) response to a congressional request to study whether the Department of Health and Human Services (HHS) is ideally organized to meet the public health and health care cost challenges that our nation faces. Congressmen Waxman and Davis asked for recommendations that are administratively feasible, could be implemented in a relatively short time frame, and would not require significant new resources. The IOM then framed the request into a broad committee charge to examine the mission, organization, and governance of the department.
Given the rapid pace of change in scientific knowledge and health care delivery, the fact that some priorities and funding levels may change as administrations change, and the reality that management styles and methods differ as new secretaries are appointed, the committee does not believe there is an “ideal” organization for the department. However, the committee does believe that HHS is ideally positioned to lead a coordinated national response to both enduring and new health challenges, and the committee’s recommendations are intended to support that effort.
The committee also recognized that the department’s management and program responsibilities are challenged by health care costs that are rising faster than national economic growth, differences in medical practice that are costly and undermine quality of care, and the growing number of uninsured. The unprecedented strain on resources means that other important roles beyond safeguarding federal health programs, such as supporting advances in medicine and technology or rapidly responding to emergencies, are also at risk.
OCR for page R14
HHS in the 21st Century: Charting a New Course for a Healthier America
The committee’s recommendations would change the department in ways that allow it to leverage its purchasing power, relationships, workforce, and impartiality to affect both the future direction of our health care system and our population’s health. The majority of recommendations reflect the experience and knowledge captured in the management literature—and validated by the experience of committee members—about creating high-performance organizations. Whether for-profit, nonprofit, or governmental, the principles for institutional success are similar.
For the committee then, it followed that HHS should first establish a vision, mission, and implementation strategy that unite all parts of the organization in achieving a specific set of measurable goals. The department should also align its agencies and programs in order to coordinate, cross-pollinate, and mutually reinforce currently separate efforts aimed at achieving similar or related goals. Once aligned, the department will be in a stronger position to support improvements in efficiency, effectiveness, and outcomes across the entire health care system. The committee also recognized that the positive impact of changing organization, systems, and cultures will occur only if qualified people are in place. Therefore, strengthening the HHS workforce, as well as the health care and public health workforces, is essential.
Ultimately, the committee was concerned that maximizing HHS’s potential to bolster public- and private-sector efforts to reverse troubling trends in health measures and costs requires a different relationship with Congress. The committee envisioned a “new compact” with Congress that would require HHS to implement a rigorous decision-making process and have greater departmental accountability for informing Congress about progress toward its goals. In exchange, Congress would grant HHS the greater flexibility and management authority necessary to fulfill its mission.
The committee hopes that its report will be of interest to multiple audiences. However, we hope that our recommendations will provide specific value to Congress and the next secretary of HHS, as they work together to develop a road map for the department in meeting twenty-first century health challenges and improving the health of the nation.
I want to thank members of the committee for investing their time and energy in developing this report and producing recommendations based on sound research and reasoning. IOM staff was also deeply committed and supportive, and I especially appreciate Harvey Fineberg’s
OCR for page R15
HHS in the 21st Century: Charting a New Course for a Healthier America
encouragement. Our committee was diverse in experience and background and not always like-minded. Nonetheless, our deliberations, often energetic and spirited, were always characterized by the free exchange of ideas, creativity, and respect.
Leonard D. Schaeffer
Chair, Committee on Improving the Organization of the U.S. Department of Health and Human Services (HHS) to Advance the Health of Our Population
OCR for page R16
HHS in the 21st Century: Charting a New Course for a Healthier America
This page intentionally left blank.
OCR for page R17
HHS in the 21st Century: Charting a New Course for a Healthier America
Contents
SUMMARY
1
1
INTRODUCTION
21
2
DEFINE A TWENTY-FIRST CENTURY VISION
39
3
FOSTER ADAPTABILITY AND ALIGNMENT
55
4
INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM
87
5
STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES
105
6
IMPROVE ACCOUNTABILITY AND DECISION MAKING
125
7
THE TRANSITION
147
APPENDIXES
A
Acronyms and Abbreviations
159
B
Letter from Congressmen Waxman and Davis
163
C
HHS Organizational Chart and Missions
165
D
U.S. Secretaries of Health, Education, and Welfare (1953–1979) and HHS (1980–Present)
169
E
Recommendations Directed to Congress
171
OCR for page R18
HHS in the 21st Century: Charting a New Course for a Healthier America
F
Dissenting Opinions on Recommendation 3a
175
G
The Reorganization Option: Views from Former Secretaries of the U.S. Department of Health and Human Services
191
H
Statutory Framework for the Organization and Management of the U.S. Department of Health and Human Services
209
I
Committee and Staff Biographies
263
INDEX
275
OCR for page R19
HHS in the 21st Century: Charting a New Course for a Healthier America
Tables, Figures, and Boxes
TABLES
7-1
Transition Steps,
150
G-1
Confirmation Dates for Initial Appointees to Key Department Posts,
205
FIGURES
1-1
Federal budget by department: actual spending FY 2007 (showing mandatory and discretionary spending),
22
1-2
Distribution of HHS actual expenditures, FY 2007,
28
1-3
Public Health Service budgets, by agency (actual spending FY 2001, FY 2003, FY 2007, and President’s budget request, FY 2009),
29
1-4
HHS mandatory and discretionary budget allocations, 2007,
30
3-1
Key factors in personal and population health,
70
4-1
Relationship between quality of care and Medicare spending, by state (2004),
91
4-2
Medicare spending for hospitalizations and inpatient physician services per decedent in the last two years of life among patients with at least one of nine chronic conditions receiving most of their care from selected Council of Teaching Hospitals (COTHs) integrated academic medical centers (deaths occurring 2001–2005),
92
C-1
HHS organizational chart,
165
OCR for page R20
HHS in the 21st Century: Charting a New Course for a Healthier America
BOXES
S-1
Statement of Task,
2
1-1
What Is Public Health?,
26
1-2
Recommendations,
34
2-1
Other Federal Departments with Major Health Programs,
42
2-2
Committees That Oversee HHS and Related Appropriations,
43
2-3
The Results of Increasing Health Care Costs,
50
4-1
Value in Health Care,
95
6-1
Selected Goal-Setting and Reporting Systems,
128
7-1
The Secretary-Designate—A Scenario,
148
F-1
Recommendation 3a,
175
