Stuart Altman Interview Stuart Altman: Stuart Altman. I'm the dean and Sol Chaikin professor of national healthcare policy at the Heller Graduate School at Brandeis University. You spell my name S-T- U-A-R-T A-L-T-M-A-N. Male Voice: [Inaudible] Stuart Altman: Okay, sounds good. All right. Jennifer Muldoon: Okay, Doctor Altman, why did you choose to work in the field of health services research? Stuart Altman: Good question and not an easy answer. I was trained as a classical labor economist, had no training or background in healthcare and wrote my dissertation on unemployed married women. This was in the middle 1960s when there was concern by some forces that women really were not interested in being in the labor force and that their unemployment was not something to worry about. I sort of began to look at it and came to a very different conclusion - that women were here to stay and that we're going to become part of it. And then through a whole series of flukes, I wound up becoming very close to a group that moved over to what was then HEW. And they, in 1967, became concerned about one of the ongoing issues of the shortage or nurses in America. They called me and asked me if I would look into it since they thought I had some knowledge about women in the labor force. And that got me into some understanding of healthcare. And then through a whole series of rather interesting events, I wound up in the early 1970s, '71 to be exact, becoming the chief health policy person in the federal government in healthcare, with, as I said, almost no background in healthcare. But being a trained economist, I was interested in issues and that led me into a complete career, an exciting career, in health services research. Jennifer Muldoon: And in your opinion what are some of the most significant contributions of health services research? Stuart Altman: Well, health services research has really blossomed and is now a critical force in our whole healthcare debate. When we started in the late '60s, early 1970s, the health services research community was quite small, and while there were significant accomplishments of the community in public policy - and they had a lot to do, I think, with the creation of Medicare and the early involvement of government in healthcare - they was just the beginning. And since 1971 we have seen an explosion in the issues that government at every level - state government, federal government, as well as the healthcare community in general - get involved in and that has pushed, first of all, substantial resources into health services research, but equally important and because of - the fact is that the issues that we face in this country had become so complicated that no matter which issue you face and which side you are on on every issue, they need health services researchers to backup their, essentially, often political findings. Jennifer Muldoon: What are the biggest opportunities for the field of health services research? Stuart Altman: Well, I think it's very important that as a field we maintain our independence, neutrality, if you will; that we don't get drawn in to purely politics without good, solid research behind it. That doesn't mean that we shouldn't take stands on political issues, but we, as a field, need to be very concerned about the purity, if you will, the objectivity of our research. Unfortunately, in the current environment, the research community is often used by various forces - pro and con - on a particular issue, and there are often times when there are groups of health services researchers that are for hire, which is not helpful. So one of the critical areas is for the research community, in total, and Academy Health, in particular, to maintain its independence and maintain the quality - the high quality - of its research. Jennifer Muldoon: What advice would you give someone thinking of beginning a career in health services research? Stuart Altman: Well, this is an exciting field. I mean, it just keeps growing and growing. It is, if not the most important public policy, social policy issue, pretty close up there. You know, this country spends two point three trillion dollars. It's sixteen and a half percent of our GDP and yet we have almost fifty million uninsured and our healthcare cost is really sort of affecting the ability of our system to function. So the issues are very real. It's an exciting field. It's not going away. It's continuing to grow. I have no hesitation about encouraging any young person who wants to be a force in an important area to go into health services research. Jennifer Muldoon: Now thinking back to the early days of AHSR, why did you become involved in helping to form a new organization, the Association for Health Services Research? Stuart Altman: Well, as I said, I was very fortunate almost sort of in a scary way, but in a very important way - of getting into healthcare through the policy world as opposed to through the research world, even though I was trained as an economist. As I said, my background was fairly limited in healthcare. And then I took on this role in 1971 where I was right in the center of the major policy issues, and I leaned very heavily on the limited number of health services researchers to help me do my job and to help the country make better decisions. And I realized two things - that while we had some very talented people in the field, there were huge issues that really were not researched - we really didn't know the answer to - and second, that we needed to bring a lot more people in. And most importantly, which helped push me to become part of that original group and the second president, was the idea that the research community needed to have a political, as well as an analytical face, to it and that an organization that pulled together both the analytics and also a policy face to it was very important. So that's what prompted this organization to get started and for me to become part of it. Stuart Altman: That's right. He and I are really a part of that group. Okay. Jennifer Muldoon: Okay, so what were the founders' goals for AHSR when it was first created? Stuart Altman: Well, it was an interesting group. I think it was made up of two factions. There were those of us who were pushing for health services research to have a policy orientation; to be concerned about what was going on here in Washington; to try to influence events, but also influence the field. And then there was a group that were much more appropriately concerned about furthering the field and improving the quality of health services research and improving people coming in. And it formed a good marriage of two groups of people. And then, fortunately, we had a leader who really combined both of them, and that was Cliff Gaus. I mean Cliff, in my mind, was the sort of the intellectual force that not only created this organization, but pushed it forward. And he really had both sides. Jennifer Muldoon: How has your involvement with AHSR influenced your career? Stuart Altman: Oh, it's influenced it in many ways. First of all, it educated me in many ways about all the different fields. I got to know people who were in the field. It set in motion a lot of further research that I've done. And it's also allowed me to sort of branch out and become, hopefully, a much better researcher and much more involved - I continue to be very involved in the policy arena, but often I continue to look to the research community for good ideas and also what, in fact, is working and what's not working in our healthcare system. Jennifer Muldoon: Now thinking back to the early AHSR annual meetings, what were the important health services research issues of the day? Stuart Altman: Well, the two dominant issues that were primary in the early 1980s unfortunately are still with us today and that is the cost of healthcare and the fact that we had, at that point, probably twenty million or so Americans with no health insurance. Quality of care was an issue, but not as important as it is today, and so we were spending a lot of time - a) trying to understand what were the forces leading to why healthcare costs were rising and what were the techniques we could use to cover every American. We also were very concerned about methodology, developing the techniques to do good quality research. And then, finally, developing data sets. We had precious little information, and the information that was with us often came from what we called financial sources, and so you needed fairly sophisticated techniques to pull out from these limited data sources the information you needed. So it was a combination of methodology, working about costs, working about quality, somewhat, and partly about coverage. Jennifer Muldoon: What are some of your favorite memories of the AHSR annual meeting? Stuart Altman: Well, back then, the small group of us - and I mean a very small group of us - were the ones that put - the idea of actually having an annual meeting was kind of like a big bold step and the first meeting we didn't even have a meeting. What we had was a booth at the American Public Health Association - I think it was in Montreal and we didn't even have enough money to have, to fund our own meeting or even a room because the hotel charged all these corkage charges, so we snuck alcohol up the back stairway and we, Cliff and I, had sort of taken a suite, and the first meeting we had was in our suite. And we invited everybody with big AHSR pins to come and join us. And we found, my God, people are really interested in this, and after a couple of years, he, and by that time we had hired this really wonderful woman, Alice Hirsh, to run AHSR. And the two of them, with my involvement and a few others, put the first meeting, and I remembered very well it was in Chicago. The reason why it was in Chicago was we had a guaranteed audience in Chicago because the AMA was there, the American Hospital Association was there, Blue Cross was there, and they had a number of health services researchers. And so the first several meetings were in Chicago and I was a little nervous. I was afraid to ever leave Chicago - that we could never have it any other place - but Alice and Cliff convinced me that this was going to make it and we could have it any place, and they were right. Jennifer Muldoon: Where do you see the annual research meeting twenty-five years from now? Stuart Altman: Well, first of all, it's hard to believe that we won't continue to have it here in Washington. And I think over the last several years we've had it in Washington and then someplace else - sometimes on the West Coast, sometimes in the middle of the country, sometimes on the East Coast. I don't see any reason why that won't continue. I don't know - we may decide to have it in Paris, you know, because it's truly become an international field. So every once in a while having it in Paris or London or Madrid or something like that might be fun. I hope I'm still around to go. Jennifer Muldoon: What can Academy Health do for the future of health services research? Stuart Altman: Well, first of all, I think the linkage of the health services research community to Academy Health was critical, and David Helms and the organization has been fantastic because it recognized the importance of promoting the field, but it also understands how Washington works and the need to continue to push Washington and the funding source to fund health services researchers and also to make the data available so that we can do our work. So Academy Health has been critical. Jennifer Muldoon: And that was the last question. Thank you very much. Stuart Altman: My pleasure.