2017 Walsh McDermott Medal
An Interview with Barbara J. McNeil
The National Academy of Medicine awards the Walsh McDermott Award annually to an NAM member for distinguished service to the National Academies over an extended period of time. Barbara J. McNeil, Ridley Watts Professor and founding head of the Department of Health Care Policy at Harvard Medical School, received the 2017 award for her nearly-40-year history of volunteer service. In the following interview, Dr. McNeil discusses how she got her start in health care policy, why she volunteers with the National Academies, and why it’s so critical for clinicians to be engaged in public policy.
How did you get your start in health care policy?
After my residency, I began work in decision analysis and cost-effectiveness analysis as applied to new technologies in radiology. New technologies in radiology were just beginning their ascent into the routine practice of medicine, (for example, the use of computed tomography, nuclear medicine and ultrasound). This work led to my appointment as Director of the then Center for Cost Effective Care (CCC) at Brigham and Women’s Hospital. My colleague, Tony Komaroff, and I worked on ways to improve care and cost effectiveness largely by reporting on the use of good practices and cost outcomes at the departmental level. Consulting firms and other institutions soon followed our strategy. This led me to become a part of the first group of Commissioners on the Prospective Payment Assessment Commission (ProPAC, the predecessor of MedPAC). At the time, diagnosis-related group (DRG) classification (how inpatient stays are classified for Medicare payment purposes) was just coming into play so I was able to contribute through the work I was doing at the CCC and through my own research. At ProPAC I served on the subcommittee for diagnosis and treatment; this group made recommendations around how to incorporate new expensive technologies into the DRG system. At the time, some new technologies and drugs, like tissue plasminogen activator (TPA), were very controversial because of a lack of data on their effectiveness. There was a lot of disagreement on whether and how to reimburse these new innovations.
What motivated you to establish the Department of Health Care Policy at Harvard?
At the time, the Dean and Executive Dean of the medical school felt that the medical system was changing so rapidly that it was essential for physicians to play a more active role in policy development. They also felt that a department with a broad and full-time faculty devoted to health care policy could provide basic research that would help the health care system. Medical schools were not actively integrating policy into their curricula, and we felt it was important that our students at least begin to think about how they can (and often do) play a role in larger policy decisions that affect their practice and their patients. Many other schools around the country soon followed. I was grateful for the opportunity to lead the effort at Harvard. Now we have a required policy course for all of our students and there’s a lot of interest. Health policy is an important part of their lives.
Why is it important for practicing clinicians to be involved in policy? How do we get clinicians actively engaged in policy?
Clinicians are a critical link in policy because of their ability to identify problems that can influence cost and quality of care. They can also provide deeper understanding for analytical results that may not seem obvious to someone who doesn’t work in health care.
Getting clinicians involved in and engaged with health policy is easier said than done. Sometimes advocacy from clinicians is helpful but policy also often requires hard data to support change. There needs to be a nuanced balance between advocacy work and actually doing analytical research to support a decision.
What is the most important thing for the public to understand about your field?
Health policy can be quite complicated. An ideal world would be one in which detailed data analyses drove all decisions, but politics obviously often play a role. My hope is that the public will understand and support the need for better incorporation of data into policy decisions.
Any thoughts about how we can better engage the public on important health and science-related policy issues?
To start, we have to have good data. We need to have evidence that something works or doesn’t work. We then need to go out of our way to present this evidence at public conferences so it can be reported widely to the general public. Most new studies are published in scientific journals that the general public can’t access. We must make sure the evidence is easily available to them and that they can understand it and begin to engage in conversation.
You started volunteering at the National Academies early in your career. Why was that so important for you?
In the early 1980s, shortly after my election to the Institute of Medicine (now the National Academy of Medicine), I was invited to join the Board on Health Sciences Policy under Sam Thier. I was thrilled to join because it gave me an opportunity to learn and collaborate with many different experts in the field. The National Academies provides a neutral space for us to work on issues that greatly impact the country. Of note, I’ve been honored to work on a number of projects involving technology assessment and cancer. I believe the work the National Academies influences the country in deep, impactful ways.
Why have you continued to volunteer your time with the National Academies over so many years?
I’ve learned so much from all of the projects I’ve contributed to, and I hope that through my work, and that of others, we help improve quality without increasing costs. The NAM has a huge role to play in ensuring our nation’s well-being. We are at a critical point trying to balance cost, access, and care quality, and we are in need of a body like the NAM to provide evidence on how we can best balance these so our country can thrive.
Tell us about one of your favorite National Academies projects. What kind of impact has it had?
I’ve served on two consensus studies on breast cancer: Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia and Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis. It’s hard to say that these works were pivotal but in the past twenty years there has been considerable improvement in the diagnosis, treatment, and quality of care for patients with or suspected of having breast cancer. I hope these reports played a role.
What advice would you give to future committee chairs?
The success of a committee depends on a strong relationship between the chair and the staff. Both have to be extremely knowledgeable about the topic, but they also need to be very committed to the project’s success. A balanced committee also has a huge impact on the final product. A committee needs experts in the field of study, but it is also necessary to have a balance between opposing views and opposing stakeholders. A diverse, interdisciplinary committee can make all the difference in the production of a successful report and set of analyses.
What advice would you give to scientists and scholars who are just starting out in their careers?
Get good analytic training! If you are getting a medical degree without a PhD, find ways to train in analytics. Even if you don’t think you’ll ever use it, you will, and it’s critical that you know how to do so. For those completing a PhD/MD, start your postdoc at an excellent university, find an unselfish mentor, and find a niche that you can work in. Start with small projects, develop funding, and collaborate with other individuals or groups. As much as possible, find ways to team up with national groups like their professional societies.
Tell us about some of your role models. Is there anyone in particular who has made a powerful impact on you throughout your life and career?
During my residency, Dr. S. James Adelstein was chief of nuclear medicine, and he encouraged me to apply cost effectiveness and decision analysis to medicine. At the time, competing technologies in radiology were abundant, but criteria for their use were limited. He suggested I learn from Howard Raiffa’s audio texts — there was no published book at the time, and all of Howard’s examples involved drilling wells for oil!! These audios helped me begin quantitative investigations in a new field of study. Jim was an unselfish mentor and also one who helped me become a much better researcher.
What is the most important trend or issue in health care right now? What should people be paying attention to?
There are so many critical areas, especially when considering health care quality and cost. However, when I think about the future, I am most concerned that our payment systems may not keep up with the advances occurring in basic science (new drugs, new delivery systems, and new diagnostic tests). We need to refine payment to account for advances as research gives rise to new technologies and more efficient innovations.