Academy Health Interviews 10-12 Gordon DeFriese, David C. Colby, David Blumenthal, Vincent Mor Annual Research Meeting Video Transcription Disk 4 Gordon DeFriese Interview Gordon DeFriese: I'm Gordon DeFriese, University of North Carolina. I was one of the founders of The Association for Health Services Research. Jennifer Muldoon: Doctor DeFriese, why did you first choose to work in the field of health services research? Gordon DeFriese: I think that like a lot of people will probably tell you, we didn't choose this field, it sort of chose us. Because of the way in which we got into it, we were trained in various disciplines, and there was nothing that anyone would have called health services research in an organized field at the time that we got our training. I was trained as a medical sociologist. I actually then ran a medical sociology training program for a few years and then ran a medical sociology training program [tape repeats] for a few years, and I'm not sure anyone ever used those terms "health services research" during the early 1960s. But after the passage of Medicare and Medicaid, there was, of course, the very important event of creating the National Center for Health Services Research. And there have been a number of people - Carl White, Cecil Shepps, Sam Shapiro, and others - who had 1 been pushing the idea of healthcare studies. And there was a study section of the public health service during the 1950s and early '60s on which all of those kinds of people served. So I actually head the term health services research as a field of study in the late 1960s when I was asked to consider a job at the University of North Carolina. I didn't actually go there until 1971 because I was teaching at Cornell, but at the time I went there, we were funded as one of the first five centers for health services research. Two years later I became the director of that center, so I directed it for twenty-eight years. Jennifer Muldoon: What are some of the most significant contributions of health services research? Gordon DeFriese: Well, there are many and, of course, it depends on when you date the beginning of the field, but I would think that one of the things that has been most important is that we have been able to really define what we mean by both the quantity and the quality of medical care and begin to not only develop definitions of it, but measures of those kinds of things. And, of course, with regard to quantity, we're all very aware now of terms like health disparities and others. We know that some people get more medical care than others. We also know that people also get better medical care than others. 2 And so those two dimensions are very important to what we are talking about. Also, I think, in the area of workforce and health resources - supply-side kinds of issues - we have developed quite a battery of studies that have helped us understand not only the volume and supply of these services, but the variability of their availability across the country. And then, finally, I think of the major things I think that we know about how to measure - practice variations and the implications of that - and those kinds of things are the things that captured the imagination of the Congress when we were trying to get them to create real significant funding for The Agency for Healthcare Research and Quality. So I think that those are some of the most important things that I would point to. Jennifer Muldoon: The biggest opportunities for the field? Gordon DeFriese: Well, I think that as we move forward in this next era in the development of American health services, I think we have opportunities not only to do a better job of documenting some of these dimensions, like quality, outcomes, effectiveness and that sort of thing, but also talking about what value we get for dollars invested. I think that we are in a position now to do something about equity, disparities and 3 that kind of thing by showing that if we implement a national health reform that we ought to try to fill some of those kinds of gaps. Jennifer Muldoon: What advice would you give someone considering a career in health services research? Gordon DeFriese: Well, it's kind of interesting. In this period, there are people who actually are considering careers in this area. When I was coming along, we weren't really thinking of it in those terms. But I think that people who choose it now, can choose a variety of pathways into the field. It can be through social science or economics; it can be even through medicine in public health, but all of the health professions are interested in health services research. So I think that a person choosing this field needs to be really firmly grounded in some discipline because health services research isn't a discipline itself and to really take some pride and serious interest in a field where specialized methods and approaches and perspectives and concepts can be brought to the table in this area. I think the other thing is to find a really good mentor - someone who can really work with them, give them opportunities, open doors for them, and help them learn what the major dimension~ of this field are. 4 Jennifer Muldoon: Thinking back to the early days of AHSR, why did you become involved in forming the new organization? Gordon DeFriese: At the time, I was still pretty young, but I was the director of a center for health services research - one of the first five funded by the federal government - and we were in our second round of funding after a hiatus of about three years when the government did not fund any centers. We were like everybody - very worried about the financial future of this field and we didn't see real advocates for us out there on the horizon. So the primary reason we got together was out of self­ interest and to make sure that the field had a visible and vocal presence here in Washington and in state capitols and other places. But I think that one of the reasons it was so attractive to me - I had been directing a center for ten or eleven years at that point, but I was beginning to develop colleague relationships with a lot of people who ran centers in other places. And having an opportunity, in a regular way, to interact with some of these people that we now refer to as the giants in the field was really exciting to me. And these people are all still doing it and they're still there. So we have all been friends and colleagues for many years. 5 I think those two real reasons were why we got together. But I think the most important was to make sure the field had a solid base of financial support. And it has had its ups and downs, but this association has been a major factor in why the field has survived. Jennifer Muldoon: How has your involvement with AHSR influenced your career? Gordon DeFriese: Well, I was one of the very first presidents of AHSR - I was the third president - but at the time I became one of the founders, I was already the editor of the journal, Health Services Research, and it became the official journal of the Association or what is now Academy Health. Of course, when you're the editor of the journal, everybody knows who you are and you know everybody so it really helped me a great deal. But I really think this field is populated by really outstanding people, and I had an opportunity rather early to get to know virtually everybody who was writing and publishing in the field. So this association really was tremendously important in that regard. Jennifer Muldoon: What was the original purpose at the AHSR annual meeting? Gordon DeFriese: Well, it was like the purpose of having the Association. We wanted to get people together, but we also needed a focal point so we could demonstrate the cumulative 6 impact of the research that was taking place in this field. And we had trouble defining the field at that point. When you would go to a social gathering of any kind and someone would say, well, what do you do? And you'd say, well, I do health services research. People would look at you for a second and then they'd walk away. They didn't have any idea what that was - or care. And I think we had a long time there where we had to convince not only other academics, but policymakers that this was, in fact, a field. And so when we began to invite leading senators and House members and others from the Congress to participate in our meetings, to come and listen to what we were talking about, we began to build an appreciation on Capitol Hill. We had a hard time, a very hard time, at the beginning pointing to evidence that we had actually made a difference. The first thing that anybody could point to for at least six years was DRGs. But I remember sitting in the Senate dining room with a very prominent U.S. Senator and several of my colleagues on the board of AHSR talking about this, and when we were able to - and we had Jack Winberg [phonetic] there with us - we just turned to Jack and said, "How about describing this whole problem that you've been studying in the last few years with practice variations." 7 And as soon as he did, the senator quit eating, started focusing on it, and he said, "Now, that's a problem we can really identify with." This is why we need to get the Bill through the Congress that would up the financial support for what is now AHRQ. And it was just like night and day. They could really understand it. So we began to put together real case examples of things that the field had done that had made a real difference, and that was one of the real challenges. Jennifer Muldoon: What were the important health policy and health services research issues at that time? Gordon DeFriese: Well, at that time, cost and cost escalation was driving everything and everybody was very concerned about 'it, but there were always major concerns about workforce - whether, in fact, we had a physician shortage, whether we had an oversupply, whether we had too many of the wrong things, et cetera. Then there was, of course, thanks to Jack Winberg and others who began publishing out of the Medicare data set, which wasn't even really possible until the late 1970s and early 1980s - first 1980s when we began to really pay attention to it - when he began to publish out of those data for the New England states, we began to see that practice variations was a real phenomenon that really had really important quality 8 implications. And so I think that those are the issues that really began to capture our attention fairly early. Jennifer Muldoon: What are some of your favorite meeting memories of the annual meeting? Gordon DeFriese: Well, I think that the scale of these meetings has really changed a great deal. Those of us who got it started - actually it was phenomenal to start a new association and have three hundred people attend the first meeting. And it was really because we were able to identi-­ well, first of all, we met in Chicago for a very good reason because most of these big associations like AMA, American Hospital Association had their headquarters there so we met there. But we made it our intent to come to Washington as soon as we could, and Washington was where we knew we'd have policymaker attention. But I think what we did was we tried to link ourselves to as many professional associations as we could including associations of various kinds of physicians - internal medicine, pediatric, American Medical Association, for sure. The American Hospital Association was very supportive with their hospital research and educational trust, which owned the journal Health Services Research, and had had a long interest in it. And so I think my memories are of how quickly it 9 escalated to the point that I think we began to have two or three hundred people attending every year. And then I think that we had really, I think, something that's continued that's really kind of surprising is we have a lot of group meals where people actually sat with one another and talked about their work and got to know each other and developed networks in the field. When I walked in yesterday morning at this meeting and I saw place settings for twenty­ four hundred people, it's a little astounding, really, considering that we could have gotten them all in one tenth of that space several years ago and thought we would have had a very successful meeting. Jennifer Muldoon: Where do you see the annual meeting twenty-five years from now? Gordon DeFriese: Well, I'm not sure that it will ever get to be multiples of the size that it is now, but I think that this kind of meeting will probably continue. I think one of the things that was an argument that floated around in the field for a number of years was whether we should have only peer-reviewed material here or whether we should have solicited manuscripts and presentations that sometimes didn't even yield manuscripts of people who had important things to say about both health policy as well as the implications of this field. 10 And I think that in the future, I think it settled out, more or less. Now I don't think that people are really arguing about that. They're really interested in having policymakers, stakeholders in healthcare, as well as people who do the basic research, come together and talk about these issues. But we have to give opportunities for young people to showcase the work that they do, and it can't be done only through posters; it has to be done through verbal presentations occasionally. So I wouldn't say the meeting would change a great deal or grow a great deal more in size, but I would say that it is possible that this meeting will sustain itself for many years to come. And I think the quality and rigor of the meeting is what will determine whether it's successful or not. Jennifer Muldoon: Anything else you'd like to add? Gordon DeFriese: No, just thanks a lot for everybody on the staff for making all this meeting possible. Jennifer Muldoon: Thank you. Gordon DeFriese: Thanks. Sorry to take up your late in the daytime - 11