AcademyHealth
                  25th Annual Research Meeting
           Session I: 25th Anniversary Founders Panel
                          June 8, 2008


     Robert J. Blendon:   Hi.   Bob Blendon.   Put simply, this is

both a personal honorific thing, I think, for the group and

something we hope that for start purposes, we will have some

lessons learned for people who build research institutions and

programs in the future.

     My colleagues here came together and allowed me to

describe the rationale in my own way.    But basically, 25 years

ago, a distinguished group from very different research

backgrounds got together and believed because they have very

strong commitment that science could alter health systems

regardless of what the background was, a belief that research

could really matter.   And that they needed some sort of an

association for what was seen as still a fragile field not

often recognized by many universities, difficult having funding

and needed some identity and came together and formed what is

now AcademyHealth.

     What we want to use the time together is to ask people, as

we go around, some lessons learned about the building of not

only the academy and the association behind it, but each one of

the people here had an extraordinary [audio glitch] at research

firms in building entities over the last 25 years that had a


                                 1
huge impact on this field and having lessons for people that

might be very useful.   So, the aim of this is going to be go

around and give people in formal remarks about four, five

minutes apiece aimed at lessons that they would like people in

the audience to take away from the experiences.

     By choice, I was requested to lead, again, in four, five

minutes to remind people that 24 years ago, I was asked to kick

off the first annual meeting and I made a small number of

points and I promised my colleagues I will do this as shortly

as possible.   I was asked to repeat this and the bottom line 24

years later was, I wanted to make the point that the field we

are in was not going to look like biomedical research years

later.   It was a very different type of field.

     And there were three reasons.     One is the treatments that

we found often were very, very controversial.     Uwe Reinhardt is

in another room and is telling you for the 50 th time, one

person's price is another person's income.     So this was going

to be a very controversial field.     Two, the research we do

benefit populations but it does not benefit millions of

individuals as they see it.   So as the field went on, we would

be short of what are called grateful patients.    And just

finishing work for the American Cancer Society -- they have

four million volunteers, we do not.




                                2
     Thirdly, this type of research, when the findings would

just take years to be implemented, a new clinical treatment can

be in a hundred centers within a few months.     The fact that

health insurance actually benefit people's health could be 20

years, and before [indiscernible] so that led to something

different.   We needed an analogue and I threw out something at

the time - there were so many former deans and chairs here -

which we just called it a series of area studies, or urban

studies, environmental studies, foreign policy studies and I

just made quick points that they had a certain set of behavior

about them that was worth thinking about.

     One is the distracting thing that what are called area

studies -- most of the research follows public policy.        It

actually does not lead it.     You go to war in Iraq and you study

the Iraqis; you enact Medicare and you study Medicare.        It is

just the whole history of this that the large part of research

is done after Congress makes a decision.

     Secondly, the actual change - and the people in this panel

are incredible at this - are actually made by experts in these

fields, not by research.     Most decision-makers can never

remember reading the research; they remember hearing the people

here talk to them about it, so it is a unique characteristic.

     And just the last point is that the public that supports

these kinds of fields is actually not interested in the field


                                  3
at all; they are interested in particular problems and they

change their mind frequently.   So if you are building a field,

you have to build a capacity that is geared up to the fact that

tomorrow's problem was not today's problem.

     That is basically all we have to say and I missed one

point and I will just mentioned this because it affected this

association and field very much.       And we did not know it then

and now; that is we finished a period - and if we wanted

General Larive [phonetic], Ron Brownstein was senior political

writer for LA Times - of the most politically partisan period

in one of the periods of U.S. history.

     And it is a very simple point I want to make about this.

During the last 20 years, the two parties could not agree on

the role of government in health care.      As a result of the

inability to agree on that, they could not agree on the role of

health services research.   If you do not know what the

government does, you should be able to agree easily on what the

government should do with the research that is found.      And

actually, the almost loss of appropriations, the attacks have

to do with not the quality that the research that was done but

the question about in a world where parties cannot agree on

what government should do on health care, what should health

services researchers    quit.   That is all I have to say 24

years later and what we are going to do is honor and give a


                                   4
chance for people's insights who are so critical in the

development.

     So the first, and I think most people are aware of this,

Clif Gaus took on the first presidential role, took over

developing this.    We kidded this morning about talking to a

meeting of 300, Clif talked to a meeting of 12.           So let me turn

over this.     He was sort of the parent among parents of this and

Clif is going to set a frame for some lessons learned and then

I'm going to move it around my colleagues, and then we are

going to open up for people for questions.        Clif?

     Clifton R. Gaus:     All right, thank you.        I think I will

convene the board meeting now.      Okay.    We [cross-talking] -­

     Robert J. Blendon:     Just one quick -- I knew he -- can we

hear Clif on the back?     We are okay?     Can you hear him?

     Clifton R. Gaus:     All right?

     Robert J. Blendon:     Yes?   Okay.

     Clifton R. Gaus:     Can you hear me?     Okay.

     What I'm going to do in about five minutes is just give

you background as to why we got together and really formed the

organization; what was going in those days.        I had been in

government for almost 10 years, mentored by Dorothy Rice of the

Social Security Administration [cross talking] --

     Male Voice:     Speak to your mic.

     Robert J. Blendon:     If you speak into it.


                                   5
     Clifton R. Gaus:   I will hold it.    Is that better?

     Male Voice:   Move closer.

     Clifton R. Gaus:   I will hold it.    I moved from Social

Security Administration to HCFA, very successfully built a

pretty large health service research program in HCFA.        And at

the same time, the National Center for Health Service Research

was growing.   And around the '80s, I left and the change of

both administrations and federal budgets really brought upon

the health service research committee some serious budgeting

concerns.   And essentially, the health service research budgets

were on the table for cutting.

     And I was at Georgetown University at the time and started

to shop around with my friends, my colleagues, the idea of

forming an organization of health services researchers, but

also an organization that really dealt with the user community

as well and kind of created a home for basically researchers

interested in the same field.     We had economists, sociologists,

appraisers, researchers, et cetera, all doing work in health

services but they had no home.     And so the real goals at that

time was build a home for health service research and let's

take on some of the budgetary issues and particularly in the

federal government around health service research.

     There were two risk takers that I want to acknowledge in

those early years, this was in the very early 1980s.     One of


                                  6
them was Bob Blendon.     Bob stepped up to the plate when we

really needed it.     We had no money.   We had a small meeting, at

University of Pennsylvania, of research centers, all whose

budgets were on the table for cutting but they all thought the

idea was great.     I called up Bob - Bob was Vice President of

Robert Wood Johnson Foundation at the time - and I said, you

know, "How about $50,000 to form this association?"        Bob said,

"Well, unfortunately, Dave Rogers and I can only sign a check

for $25,000, how is that?"     I said, "I will take it."     And that

literally, that RWJ, in a very nimble and quick way, put the

money on the table to make it possible for us to organize.

     The second risk taker was Alice Hersh.     As many of you

know, Alice passed away at a very young age and tragically.

Right after we got the money, I needed to find somebody to do

all the hard work and the ground work, and Alice had been a

graduate student with Stuart and even though we had no promise

of long-term salary - had maybe, at the best, six months' worth

of a salary in the bank - Alice agreed to come.     And actually,

she was, as much as any of the board here, had it behind the

actual creation of the organization and saw through the first

annual meeting which I'm sure some of the other folks will talk

about and how we actually pulled off a meeting with 300 people

in Chicago.   Alice would be very proud if she saw us all here

on the stage today.     This was her dream and 25 years later, I


                                  7
do not think anyone could have imagined that the organization

would have had as much impact as i t has in the field had as

much impact this one has.     I hope some of the fellow prior

board members here will talk about some of those impacts.

     Stuart was in HEW when I started my career.     He was

struggling with the National Health Insurance bill at the time,

the Kennedy-Mills Bill and he remembers how little data we had

about the doctors who are co-insurance [sounds like].     You want

to comment on that Stuart?

     Stuart H. Altman:     Is this working now?

     Robert J. Blendon:     Can we hear Stuart in the back?

     Male/Female Voices:     No.

     Stuart H. Altman:     How does i t work now?

     Well, looking around this group, I had the distinction of

being the only one that had absolutely no background in health

service research which made me uniquely qualified to follow

Cliff, and the reason why is that, as Cliff pointed out, I

found myself in 1971 in a fairly senior policy position in the

government and realized we did not know what we were doing and

turned to Cliff and to Dorothy - I see Dorothy sitting there,

Dorothy Rice - and started to ask all these kind of basic

questions on what we knew and what we did not know.     And i t led

indirectly -- the RAND experiment had begun even before that




                                   8
under OEO but they were just really basic understanding that we

did not know.

      And so two things -- first of all, it was my office that

began to push at the government level the idea that we needed

to really expand the base of people who worried about (a)

providing independent, objective analysis; and second, we

needed to develop a database.   Most of the information we had,

really, was pulled together from bits and pieces, and with all

due respect to what came out of Social Security, it was basic

data and you needed to know more.

      And so when Cliff came to me after several years of having

done that, he said, "We really need to get this going."     He

could not have found a more willing supporter of his model than

me.   And we were fortunate I had moved on to Brandeis at that

time and we were one of the research centers of then HCFA so we

had a few dollars to kick in.   But the important thing was that

there were tremendously complicated policy issues that were

being made on the fly with absolutely no information behind it.

Sometimes the world has not changed all that much.   We say it

all too and --

      One last thing I will say because I really want to hear my

colleagues as well - one of the problems we have right now is

our success and that is, now, every side of every political

issue requires health services research.   And so to the extent


                                9
that this field can play a role, i t needs to carry on the

objective analysis group.     And, unfortunately, all too often,

segments of our communities [audio skips] and as a result, we

are on every side of every issue which makes for a lot of jobs,

but i t does not necessarily make for good policy.    So one of

the things that I am the most proud of, of this organization

through the years, i t has stood for independent, high-quality,

objective research.     As we look into the future, we need to

keep doing that.   So thank you for --

     Robert H. Brook:     Let me follow the conversation.   Bob,

can I follow up with RAND because Stuart raised the issue of

the sort of the critical role of the RAND study?

     Robert J. Blendon:     That is going directly to the CIA

according to the [laughter].

     Robert H. Brook:     That is a problem of RAND I think.

     I was going to make two or three comments about this.

First of all, the thing that makes all the difference in the

world is when institutions want to cooperate.     That is still

extraordinarily rare in our field.     Both success and failure of

this field is the willingness of people across institutional

lines to cooperate.     What made RAND such an exciting place to

be was that UCLA was a full partner.     And what made UCLA so

exciting in this field was that RAND was a full partner.       And

that required the regents, the chancellor and everybody else to


                                  10
agree.   To those of you that do not know, RAND is, in essence,

a teaching hospital of UCLA.     I mean, it has the same status.

     We tried to replicate that model because RAND now exists

in a few other cities and I can only tell you there is not a

single place yet in this country or a single other academic

institution that is willing to actually say that that is a

model that is worth doing.     And I think that is a huge mistake

and one of the things that we could solve.     I do not know how

much you want me to comment about now but you want me to use up

my two minutes?

     I'm going to say a couple of things.     One, the last 25

years because of the people up here, we have actually been able

to get all the easy work done.    When we began the health

insurance experiment, nobody knew how to measure health in the

policy study.     Now, nobody would even question whether you can

measure health.     There are a few psychometricians running

around that want to spend another $4 billion trying to measure

a little bit better, but the bottom line is we are 99 percent

of the way.     Nobody really knew how to apply economic modeling

to health care very well.     Now, again, we are at a stage where

there is not much more to do with the econometrics or

statistics in this field.    When I began and when people began

up here, nobody could measure quality of care.     We can measure

quality of care.


                                  11
        So we are leaving the new generation at this moment with

all of these tools so that can be used to provide objective

information to help make better policy decisions.           The

question, really, at the moment is: Can we change that culture

of using this information?     How do we want to do it?

        I am a little bit fearful.        I look through the 2,200

registrants for this meeting.        I think I identified two that

come from the for-profit sector.           I am all the way on the right

or my right, at least.     I asked some of my clinical scholars

that come into the program, "Any of you Republicans?"             When was

the last time I hired a Republican?           I have not hired a white

male in a long time that is Protestant but when do I hire a

Republican, white male or anybody as a health service

researcher?     I'm serious.   I mean, if we really are going to

bring this country along, and produce subjective information,

how do we make this a field that has equal participation from

both the right and the left?      I'm a little bit sad that we were

not able       one of the outrageous things I said - I have said a

lot of them - was I wanted to billionize ARC and in its

previous name -- actually people looked at me and thought I was

nuts.    They had a good reason to do that.        We have not achieved

that goal of trying to produce a billion dollars into that kind

of an agency even today and that is a big mistake and a big

problem.


                                     12
     And last, I think we are going to have to figure out, now

that we have all the tools and the information, how we really

are going to go about making change?        I would ask this

audience: Will the basic scientist make women immortal before

or after we have universal health insurance?        I mean, which

will come first?    When 40 years ago, we began the RAND Health

Insurance Experiment, the president was not going to sign off

on this study because he said it is going to take 15 years to

get the results and by then, we will have National Health

Insurance, why do we need them?        Just do as Bob says - study it

after it occurs.    What is going to occur first now?      Are we

going to really have health insurance for everybody?           What do

we need to do?     I would suggest two things.     One, I think it is

incumbent upon us not to just continue to talk with each other.

One, we have to talk with communities and try to increase and

change health services research methods to really include

community-based participatory research methods.

     And then lastly, I have been saying things that I might as

well say them since I am now old enough that it is not             I am

not going to get another position in life, but if I could do

one thing, I would bet dollars for doughnuts that we will have

no health policy change by the year 2010.        And by that time,

all physicians in the country are to treat everybody and their

staff in Congress and in the Executive Branch, whoever wins, as


                                  13
if they had no insurance, that the only way we are going to

actually produce a change and force Washington to do something

is to actually treat the decision-makers and their families as

if they had no insurance.     Would that not be a fun experiment

to do and I would be happy to let Bob do the public opinion

poll right away [laughter].

       Robert J. Blendon:   Larry Lewin.

       Lawrence S. Lewin:   I really have respect for everybody on

this panel and not least of which was Stuart [audio glitch].

But I have to disagree with Stuart in one respect and that is,

he said he was the only one who had nothing to do with health

services research and I probably was even further away than he

was.   As a management consultant involved in working with

states and institutions on implementing, I was especially moved

by what I heard this morning on his talk.       I thought about

implementation of science is very appropriate.

       So why was I involved in founding this organization if I

was not a health services researcher?      Well, at the time I was

dealing with a very difficult issue.       I had a contract with the

then NCHSR to run a series of meetings for state and local

officials on how they could make use of health services

research in making policy.     And the rationale - Rob Fordham was

the father of all of this - was that the way you get people to

use information is to learn how to make decisions and if we


                                  14
could teach them about how policy is made, maybe they will find

information helpful.

     And so we had these week long workshops and the biggest

challenge we faced was that bridge between policy and research.

And as my colleague, Jack Needleman, once said, "A policymaker

asks a question; the researcher reformulates it to adapt to the

data and the methodology at hand, and when he or she is done,

the policymakers are often left with an unanswered question".

So bridging that gap, getting policymakers and health services

researchers to talk to one another was really a major challenge

that we were facing at the time.

     So when we sat down together to figure out what this

organization should look like, one of the disputes we had - and

it was a very hot dispute - was whether this should be an

organization of health service researchers or of health service

researchers and users.   And the arguments on both sides were

very strong.   The compromise that we came up with was that,

"Yes, we would include users and policymakers, but we would

also have methodology workshops."    And I'm proud to say that I

was the one who first recommended, as a non-methodologist, that

we had this -- it was my way of trying to win the point.

     But I have to say that of the things that I have observed

at these meetings, those methodology workshops have really

proved to be wonderful and it has taught me a very important


                                15
lesson and that is, if you have a membership organization, you

have to do more than say to people, "We are here.        You should

support us because what we are doing is important."        You have

to give something back to them.        And I think that what this

organization has given back to its participants, to its

members, not only in methodology and understanding of what one

another is doing but also to create a career field as well as a

voice on the Hill, has been extraordinary.        I'm very proud to

have been associated and when I looked out from this stage this

morning at 2,400 people, seeing that there are plenty of

representatives, I have to tell you, big difference.        Thank

you.

       Robert J. Blendon:   Barbara?

       Barbara J. McNeil:   [Speaks away from the microphone] my

assignment asked me to think about what i t was like to take

some of the early thoughts about the creation of this

organization and to translate them into the establishment of a

department in a medical school.        And the idea here was that

this organization was started in 1983 and a few years after

that, Harvard Medical School decided that i t was time for

physicians to interact more directly with policymakers in terms

of both research and subsequent decisions.

       So I think my message from that would be the following: we

have now established a department that has about 22 fulltime


                                  16
faculty who sit in the same place; there are 12 others who are

associated with us but do not sit in the same geographical

area.     And I would like to say the following.    I do not think

my remark should be construed as a lesson in history but

potentially as a lesson in future planning because everybody

around this table will soon pass on to greener pastures - red

or blue, depending - and we will be replaced by people in this

audience, or people elsewhere in the meeting.       Or other groups

of health policy researchers will be found in the country.

        I want to say, therefore, a little bit about what I think

the recipe is for success in building a research group that has

a rich portfolio, and some of the criteria that I would give

are obvious.     First of all, you should hire very talented

people.     No question about this.    And they should represent

multiple disciplines - obviously economists, sociologists,

statisticians, physicians -- those are pretty clear, no-

brainers.

        The other part of it though, I think, is the following.

Such individuals should be nice.       And I think that is really

important because [cross-talking] -- yes, that was one of the

classes from kindergarten, because -- what was the name of that

book -- Everything I Lea=ed in Kindergarten.        That was one of

the lessons because everything that -- if we are going to make

any advance either locally or nationally, it is because we have


                                  17
done collaborative research, bringing together our colleagues

from multiple different disciplines and people are not going to

want to work with us unless we have a nice collaborative way

about us.    So smart is important, multi-disciplinary is

important, but nice is really important.   And I cannot

emphasize that enough.

     The other thing I would say - I was talking about this at

lunch today with somebody - is in establishing a group, I know

that it is the habit of physicians frequently when they take

new jobs to say, "I'm going to take that job only if you give

me five positions, and x million dollars, and 600 more square

feet per year."   There is a huge laundry list and I actually

think that is the wrong way to go.

     I think in some sense we should be in the pay-for­

performance mode in building a research enterprise, and that

leaders of such groups should be given new positions, new

space, new computers, new whatever, conditional upon their

success.    So I personally would be the first one to scrap any

kind of big offer letter with 16 different lines in it that get

negotiated back and forth over several months.

     The other thing I would say is -- and this applies to

researchers individually and in a group and in a department.      I

think over the next few years, we do not know which way the

world is going.   Bob has mentioned that, Larry, Stuart,


                                 18
everybody and therefore, we have to be absolutely flexible in

what we do.   We have to take on any kind of project that comes

our way even if i t might seem a little bit tangential because

we never know what leads are going to come out of that that

will lead to insights in some way and then some arena in the

future.

     That is it.

     Robert J. Blendon:     Bill?   The balance with two different

schools is terrific.

     William P. Pierskalla:     Well, a couple people have

mentioned how they came out of different areas.       Well, I'm

quite a maverick in this group, too.       My background is

engineering and mathematics and business.       And I do not really

do health services research in the context of this society;

although, I was there at the beginning.       As I recall the

beginning and Cliff mentioned this a little bit, those of us

who were running centers, and I was running the Leonard Davis

Institute, we had a million dollars a year coming in from the

National Center for Health Services Research under a grant, in

our case, to do management-based research.       The other one is

from our policy base.     And that was facing extinction because,

as I recall, the national center budget was going like from $50

million to $25 million in one cut.       And we were basically all

out of that money.     I mean, we would have been in business,


                                    19
maybe, but we were all out of that money.     And we had to do

something about it and we said we have to unite because we

cannot fight it individually.     We have to do it collectively.

And in fact, we did and we were very successful.     And Alice

Hersh played a monstrous role.     I mean, she was just amazing

how she helped shepherd that.

     And so another thing, I want now to talk about Alice.         I

was the first treasurer of this organization [audio glitch] in

-- nominally, treasurer.     Alice did everything and she took

care of all the money, she made sure everything happened and it

was just amazing.

     Now to get back to some of the comments that Bob asked

about.   I would like to differ to two colleagues, too, Bob

Brook and Bob Blendon.     We have not solved all the problems.

As I recall, in the late '70s, I got involved in doing research

in health-related areas.     What was the biggest issue?   Costs

were rising at twice the rate of the CPI; we were already at 9

percent of GDP; and it was going up at this phenomenal level,

and what could we do about it.     Minnesota tried to a grand

experiment in HMOs.   Most of Minnesota was being pushed or

jumped or something into HMOs; we had to cut cost.

     In New Jersey, the Secretary of Health - I cannot remember

her name, Joan [phonetic] somebody - looked up to Yale and Bob

Fedder [phonetic] up there was talking about DRGs.     He said,


                                  20
"We can use DRGs to manage things better and cut costs through

better management."     She looked and said, "I can use it to cut

my payments."    And sure enough, she put DRGs in around 1982,

'83 and she did cut costs, went to Maryland and then all of a

sudden HCFA picked it up and went all over the country.

     We do not know how to control costs.     We are still in the

same problem.    Only now, we are talking 16 percent of GDP

versus 9 percent.     We have not even dented that problem

although prospective payment helped.     HMOs helped, although we

did away with HMOs in the last few years because the better way

is to retreat than to try to fight the system, controlling and

rationing care because basically HMOs and managed care was

rationing care in some way or another.

     So we solved a lot of problems, I agree, and Bob said

quality.   When we were doing quality back in the early '80s, we

would talk about quality and you would get to the physicians

and they would say, "You cannot measure quality.        We know

quality, we do quality.     You cannot measure that."     It was a

little bit like beauty.     How do you measure beauty?    Well, that

has changed.    We measured them and we do a pretty decent job

and it is getting better all the time.

     Finally, the other way I'm a maverick a bit is I work on

management problems as distinct from policy problems.        I get a

great deal of satisfaction working with hospitals and physician


                                  21
groups and nursing groups and so on, trying to solve the

problems they have.   Sometimes it has policy implications like

one of our members in the audience here, Joanne Levy, and I

worked on a project to try to figure out how West Virginia

could have more physicians working in rural areas and because

they were spending a lot of money on physicians and getting

virtually no benefit out of it.

     But I like to work on problems personally and one thing I

noticed is, a little bit missing in our organization here is

that we are not working on the kind of problems that turn me on

and which are, for example -- which I'm getting involved in now

-- we have a lot of vets coming back, men and women, from Iraq

and Afghanistan with multiple concussions and traumatic brain

injury, how can we build a system through the DoD and the VA to

make sure that these people get the treatment they need over

the course of their needs, which can be quite long.        In fact,

some of them may never ever come back to full recovery.        How

can we build a system that really cares for these people?        That

is sort of the level I work in.        I'm not at the policy level

but I applaud the policy level.        Do not get me wrong, we have

to do that or we do not see any change at the higher plane.

     That is all.

     Robert J. Blendon:   A quick apology from the chair here,

since these are long-term household words.        It is Bill


                                  22
Pierskalla, University of Pennsylvania, Barbara McNeil from

Harvard Medical School.      Again, just the apology of not making

sure that we have recognized for that [sounds like].

      Let's do Ed Hughes, Northwestern.

      Edward F. X. Hughes:     Correct [sounds like].   It is great

to be here and we were asked to think about three or four

things that either we had learned at building institutions that

we could share [background whisper] provided -- can you hear

me?

      Male Voice:   No.

      [Cross-talking; speakers speak away from the microphone]

      Edward F. X. Hughes:     Thank you for your indulgence.

Well, it is not just the CIA after you, too.

      We were asked to either provide a prospective on lessons

learned from building successful institutions or about the

field itself.   And what I thought I would like to do is make

three points about the field itself over things out of zero

over 25 years and things I hope could be observed over the next

25.   But I also want to make a little kind of footnote to

history.   Cliff is absolutely correct in describing how this

organization began.       It was at the University of Pennsylvania,

I was at the meeting that took place, but I want to speak for

the Midwest, that some of us came from that hallowed part of

the nation, with independently original ideas.       We also needed


                                    23
an organization.    And that was what made it so exciting, that

we all came - I mean, not all of us but a number of us did -

with the idea something had to be done, that there really was a

need in the country -- not that there was a need in the

country, there was a universe of mostly then young-but-not-so­

young people committed to this field.

      I was asked: How did I choose to go into the field?        I did

not choose to go in this field.        The field found me.   I was in

it.   And there was no field.   We were doing what we thought was

right and I was in the same spirit of being just having my

decision to become a physician.        The goal was to help people.

And I thought this was the way you could help the most people.

And, Bob, I'll disagree in the most charitable sense that this

field does benefit individuals.        You do not see the individual

but unequivocally the work will be done.        Quality, decision­

making, managed care - it benefits individuals.        That is why we

have been so successful and so important.

      So three points that I think are worth reflecting.       And

what is interesting is, implicitly, one of them has been

stressed already - the first one I'll make.        The second one has

been stated three times, which I thought was remarkable.        The

third one has not really been mentioned and I'll be very proud

to end with that.




                                  24
     The first is the positiveness and Bob said how successful

we have been.   This field has been enormously successful.        And

when we started, one of the things we had to overcome in that

meeting was defeatism.   There were those that, "Well, we cannot

accomplish."    It was learned helplessness for so many years

trying to do stuff without really achieving.     But I kept saying

among others, "We can do things."     And we did it.   Bill was

talking about quality, what we did about managed care, Harold

Luft's work, John Wennberg's work which has revolutionized how

we think about geographic variations.

     What is exciting now is that, let alone, let's say the

national health insurance work but we are now getting more and

more to help people make decisions about their own health care

and I think a major frontier is essentially behavior.      How do

people adhere to diabetes regimens?     How do we get them to be

aware of those issues, that that frontier of individual health

responsibility, accountability - extremely important -

psychology and all the stuff will come there?     And so I will

also support the notion that I do not think we have solved

problems necessarily but we have made enormous advances.      And

like many other great fields, the best years are still to come.

     Point number two.   This was made by Bob as also made by, I

think, Stuart and that is, it is critical that this field

remain empirically driven.   Bob used the word "objective".        I


                                 25
will argue over this.     I have been disappointed.   I think this

organization has not been empirically,      [indiscernible] driven

but has been more inclined to certain ideological physicians

than others.    And I think its future will remain strong and

vibrant to the extent to which it is, again, empirically­

driven, research-driven, and not trying to figure out how do we

support a certain position, but what does the data show?       What

is the most efficient way for our society to pace our resources

to provide the insurance bond that you speak of, et cetera?

But we cannot be ideologically-driven.      This is very important.

     And coming from business school, I can speak with a

certain perspective that the American business community is

enormously important in our future.     And by the way, they value

healthy workers.     That is why the large employers are not

dropping out of providing health insurance.      They value healthy

workers.    And they represent for us, whether we are aware of it

or not, an enormous user community.     We have been accepted

there.     They look to us unequivocally.

     And lastly, and this point I do not think has been brought

out before, but I think it is enormously important and it has

been a guiding source of inspiration for me as I have matured

through my career, and that is the issue of sustainability.          I

heard a CBO staff person speaking recently about health care

costs.     There was not a syllable in his presentation - however


                                  26
empirically and methodologically rigorous - that somehow these

dollars were related to keeping people healthy and making them

better.   We have achieved in this nation during the 25 years of

our existence, the single most remarkable reduction of

cardiovascular mortality in the history of the world.

     It is amazing how many of us are alive.    I think it was 25

years previously there were people on this stage who would not

be here today if it were not for the advances of medicine over

this period of time.    There is nothing more precious than human

health.    I do not care what the output of society is.   Steve

Jobs will make an announcement tomorrow about the new

generation of the iPod and the stock price of what went down in

the market.   Who cares -- at one level?

     But yet think about how many people care about it.     There

is nothing more precious than human health.    The notion that

spending is too much in this nation is not appropriate - I will

argue.    Sure, we want comparative [sounds like] -- we want to

spend the money on what is most effective as compared to

effective research.    To me there is no problem at all if we are

spending 16 percent of GDP in health care, 17, 18 or 22.     When

we get to 85 percent, we can sit around and talk about it.        But

let's not be defeatist at all.    We are in the most important

business that this nation is in; we are doing the most precious




                                 27
thing that any society can do.        Let's be enormously proud of

it.

       Thank you very much.

       Robert J. Blendon:     Ronald Andersen, UCLA.

       Ronald M. Andersen:      All right?

       Male Voice:   Yes.

       Ronald M. Andersen:      Oh, great.

       Male Voice:   Just do not mumble much.     Sit next to Bob.

       Robert J. Blendon:      This is and was a tough group.   Let's

be honest.

       Ronald M. Andersen:       I wanted to talk about the early

work in National Health Survey Research and what it has

contributed and how it has changed and how that perspective

might value and help young researchers.        There are a lot of

good friends and people out in the audience.        No offense, but I

do not know how many really young researchers we have here.

       We could be celebrating not only the 25 th anniversary of

the Academy, but in fact the 75 th anniversary of National Health

Surveys and their impact on health services and research and

policy and practice.        That really is kind of startling when you

think about it, maybe not so much to many of us here but to a

lot of young folks who could not imagine that there is anything

relevant that happened in health services research 75 years

ago.


                                     28
       I think the Academy needs to emphasize here - more so than

we have - this tradition for younger researchers to learn about

the achievements as well as the limitations and mistakes that

were made, to help build what really I feel is a proud

tradition for the future.     I feel strongly about the import of

that tradition as I was thrown into the middle of it as a 24-

year-old, all but dissertation to direct the national survey of

medical care use and expenditure in 1963.    And I went to NORC

to interview for this job, and Jack Feldman, who was a research

director and the original methodologist of a series of foreign

national surveys done by NORC and HIF for the Center for Health

Administration Studies at Chicago, said to me, "Ron, this is

not like studying cardiac farmers in Indiana" -- where I had

spent the last three years.     I suppose he was suggesting that

this was a limited-number-of-people study being studied and

maybe not so many people know about them or necessarily care

about them.   He said, "The nation will look at your results and

compare them with other sources," like some of the stuff

Dorothy Rice was producing at the time, "so your results need

to be sound and accurate."    So to try to compensate for my lack

of experience, I really started running scared as a 24-year-

old.    I tried to immerse myself in this tradition that had gone

before.   And the previous work and results that had been




                                  29
published, they were my bible.     And some of the people who had

done that work were my mentors and my confessors.

     And I just want to share with you and think about a little

bit of this tradition and why it might be important for more of

us to know about and learn from it.     We go way back to the CCMC

studies done in 1928 to 1931.    They interviewed 9,000 families

in 17 states, the District of Columbia, and Odin Anderson

talked about this being the first effort where reformers turned

to the systematic collection of what then was the best they

could come up with as national data to look to changes in the

health care system that might benefit us all.     And they used

public health nurses; they interviewed six times over a 12-

month period, these families, and went from 1928 to 1931.      They

tried to verify conditions; they talked to physicians about

diagnosis; they tried to talk about the cost but the physicians

did not want to talk about cost.      And they were the first to

document.

     This is still going to sound familiar: 10 percent of the

families were responsible for 41 percent of the cost.      This was

the first time we had evidence of that kind of information.

The result was a recommended prepayment community-wide planning

and - what was the third thing I want - oh, group practice.

None of that came into being but there was a format that

generated a lot of interest in and consideration.      On the other


                                 30
hand, there was no systematic sampling and they did not

interview African-Americans because they did not think the

methodology was appropriate to gather information from that

population group.

     So then we go on to '35, '36, we have the public health

service doing a national health survey of 700,000 households.

They thought there was safety in numbers.     That was in urban

areas.   And they did 37,000 surveys in three rural states to

get information from rural areas, and they did include African­

Americans.   And they felt with those numbers, they could make

systematic estimates about various kinds of diagnoses, the

various kinds of diseases in the country, to use for planning

purposes.    Now, they did not again do systematic sampling but

they got the idea that more degrees of freedom were better than

less degrees of freedom.

     And nothing much happened except we still have plans on

the board for national health insurance as we have had most of

the time since the '30s -- and then the four national surveys

funded by the drug industry.    Can you imagine the first two at

the Health Information Foundation with NORC doing the work?

This is the drug industry involved.     And Odin Anderson was the

research director of those first two.     They got down to about

3,000 households and they did the first national probabilistic

sampling frame that was done for any studies.    And it came out


                                 31
of the health care field.     It was just a marvelous beginning,

and not only produced data to compare with data from other

kinds or sources such as the Bureau of Health Statistics.

     It was tremendously politically charged.      They showed

disparities in insurance coverage and expenditures and use by

income.   By that time, 40 percent of the low-income had

insurance compared to 60 percent as a country as a whole.        And

again, 10 percent of the people were responsible for 41 percent

of the cost.

     Robert J. Blendon:     I have to say thank you, Ron, just

because I promised in blood when we started here that we would

[cross-talking] --

     Ronald M. Andersen:    Let me just summarize the sale

[sounds like] of -­

     Robert J. Blendon:     I see Dorothy Rice looking at me,

"Yes, we are going to summarize."

     Ronald M. Andersen:    -- that we went through a series of

national studies and involvement.      NCHS started to do the

National Health Survey in '59, AHRQ with an emphasis on

utilization and extent and health care.     AHRQ started to do the

national expenditure surveys.    We worked with [indiscernible].

RWJ came on board, emphasized the access to care.      Blendon and

his colleagues supported the study.      National studies have




                                  32
access to care, which i t provided tremendous information I

think, to use.

     Granted we have a lot of problems, but we have made a lot

of progress.     And I think much of this data has contributed.

And I think i t is all related to what happened in the past and

I feel quite passionately that many of our younger folks do not

know about this tradition.     And sometimes they are reinventing

things that frankly go back as far as the CCMC studies.        And so

I think that is something that we really need the people and

traditions in the studies that have been done that can help

them and support them to do even more now.

     Robert J. Blendon:     Gordon DeFriese, North Carolina.

     Gordon H. DeFriese:     Thank you very much.    I do not know

if everybody can hear me, but I really feel quite honored to be

among this group of people here.       As you could tell, they are

much older than I am, so they have all been very helpful to me

and my career.     When we met in that conference room out at the

Rand Corporation in 1983, I felt very honored to be there.          I

had already been directing a center for about 10 years -

actually a little more than 10 years - and we were one of the

first five centers funded by the old NCHSR.       But then we all

had to face the music when they de-funded these centers and

then that was when they said, "Gordon, have we got a job for




                                  33
you.     You can become the director of one of these unfunded

centers."

        Anyway, I was in my second round of funding from whatever

they were called then, NCHSR, and we had met out there in Los

Angeles and some of these people I had not actually met at that

time.     But all of them I had heard of, of course, then they all

became friends.     I will say that there was one thing that was

very distinctive about that group and that is, that there were

very few real doctors in this group, people who really took

care of patients.     Bob, of course, is a distinguished physician

who was vice-chair of the Department of Medicine in UCLA, Jerry

Attrition [phonetic] as well, really well-trained in medicine

at Hopkins and so forth, was the first clinical scholar and

actually set the model in place that the RWJ then began to

implement in the early '70s.     Ed had been trained in surgery

and really was not practicing at that point.        He was at the

Kellogg School at Northwestern.        And Barbara is a radiologist

and has always been clinically active as far as I know, and of

course, she is one of the youngest in this group as well.           But

basically, we were not -- and Phil Lee [phonetic] was there but

you know, he had not been practicing for quite a while although

he had already been in at least one administration, in a fairly

prominent place, and of course, he has had several lives.       And

he has been in several of these.        But basically, we did not


                                  34
have very many clinicians.   And we learned fairly quickly that

if we were really going to do anything in this area, we really

needed to speak to clinical medicine and dentistry and nursing,

et cetera.

     But starting with medicine, to begin with, the Robert Wood

Johnson Foundation deserves a tremendous amount of credit for

perceiving the value of a training program like Commonwealth

had run before, that would enable us to bring into this field a

cadre of young clinicians who really knew about and cared about

these non-biological aspects of health and medical care.    And

you know, RWJ did try it later with both nursing and then, at

our place, we ran a program in dentistry where we trained them

at both Harvard and UCLA, but we coordinated it out of

Carolina.    Basically, they backed out of nursing and dentistry

eventually and downscaled the clinical scholarship for

physicians, but if you look at that program, it really made the

whole field of general internal medicine and general pediatrics

a good part of community-based psychiatry.    If you look at the

VA program - and I see Shirley sitting out here - we have

clinicians all through the VA system who have been trained in

this area of research who now know how to do it.    And the

mental health services research community would not be there

were it not for a lot of these kinds of people.




                                 35
     So in terms of implementation and getting ideas out there,

what we did was essentially we saw a lot of this whole field

come alive around the basic notions of health services

research.   People like Mitch who were running these centers at

Kaiser actually were creating an environment within which non­

clinicians and clinicians could work together to study these

issues, so in North Carolina we tried to replicate that.    We

tried to make it really attractive for clinical people to want

to work in an environment like this with weird people like

sociologists and anthropologists and economists and other

people, lots of lawyers and other kinds of people getting

involved.

     And so these centers, as they blossomed around the

country, became very interdisciplinary kinds of places where

the questions were more important than the discipline you

brought to study them.   And so we began to put these things

together in a way that I think was really quite exciting.

     And also I think, going back to this morning's

presentation by our keynote speaker, our chairperson, if we

think about what she had to say to us about implementation, we

have been working on these issues for many years.     And out of

these centers, have come not only a number of programmatic

strategies for dealing with health [audio glitch] but programs

like ones that we also ran in our own state and now, in several


                                36
other states where health policy units were created that were

outside the university, that were in between the university and

health policymakers.   And I think that health services research

has really been like the basic launching pad for so many things

in the field.

     Gordon H. DeFriese:    And of course, the name of the

journal was a negotiated thing that Carl White forced the

American Hospital Association to name the journal Hea2th

Services Research instead of the Jou=a2 of Hospitai Studies.

And I think that Carl White has become a really good friend.

And many years later was the professor for people sitting on

this panel including Bob Blendon.      But Carl White could sense

years ahead what terms were really going to be important and

how we should frame this thing so that we could take advantage

of i t and now we all benefit from it.     But I feel particularly

blessed by being around such a group of people all these years

and I'm also very honored to be a part of this discussion

today.

     Robert J. Blendon:     Mitch Greenlick -- we will say Kaiser

Health [indiscernible] but also the Oregon legislature.

     Merwyn R. Greenlick:     Thank you, Bob.   When I first

entered politics, I was told by one of my mentors, an ex­

governor, ex-cabinet member --

     Robert J. Blendon:     Can you speak up, Mitch?


                                  37
     Merwyn R. Greenlick:     Yes, I can speak up; I can probably

get to the back of the room without the mic.      Is the mic on?

     Robert J. Blendon:     Yes.   It should be, yes.

     Merwyn R. Greenlick:     I was told by my mentor that you are

always supposed to say, "I want to make three points," i t does

not matter how many points you are going to make.       And

sometimes I lose count but I want to make three points.

     First point, Larry Lewin and I were on two sides of -- the

Association of Health Service Research was going to be an

association for the producers of research or for the users of

health services research.     And I was trained - in the early

'60s - at the same time that Professor Andersen was trained to

be health service researcher.      We were really in the very first

generation of people trained specifically in the field of

health services research, Ron at Purdue and me at Michigan.

     Our mentors had come into the field in a very different

way, through sociology as both, I think, your mentor and mine

did or economics or administration or some other way.         And when

people came out of those other professions, they had an

intellectual community to belong to.      It was the intellectual

community of sociology where you had the big arguments or your

structure functionalists or whatever, and the economists or

your econometrician or an institutional economist, but they had

a community to belong to.


                                   38
     What I always missed was a sense of community as a worker

in the field of health services research.       And why I was so

interested in starting this organization was to build that

sense of community among health services researchers.         And I

clearly recognized we need to be talking about both the user

and the producer but I was focusing on that in a sort of a

selfish way because it was sort of lonely out in Portland.            I

mean, I had 300 people working for me but in terms of the

field, it was lonely and I really wanted to build this

intellectual community that we have built over the last years.

And you look out in that audience and that community is really

there and it was very exciting.        And I'm really happy to see

that it is not an issue so much anymore.       We do have a

community and it is a healthy community and it is a vibrant

community and it is very important.

     Now I want to make the first point, or is it the second

point?   In the mid-B0's, the early '80s, it came to me that

what was the Center for Health Services Research or the later

whatever it was called, was de-funding, there was a lot of

problems and Blendon was everything it could to keep the money

in there.   But it struck me at that point that those of us that

want to do health services research needed to translate it in a

different way in order to survive the field.       And based on the

Willie Sutton principle which I'm sure you all know, you ask a


                                  39
bank robber why he robbed banks and he said that was where the

money was, it struck me that we needed to find a way to

translate health services research in a way that could be

funded in the NIH where they lost as much money in the cracks

as there, you know, in the sofa.

     And NIH as the health services research organization,

whatever it was called, had to fund.   And I started translating

the research questions I had so that -- it related [sounds

like] to cancer or heart disease or whatever.    And it was a

little tricky; the name of my center at that time was the

Health Services Research Center so whatever I did, it always

went to the Health Services Research study sections where they

got approved but where there was no money.   I mean, they wore

funding at the top 0.05 percent at that point.    So I had to

change the name of the institution to the Center for Health

Research.

     Now, why I am making this point and I got very successful

in translating health services research questions to be funded

by the Heart Institute or the Cancer Institute or the Aging

Institute or NIDA, for example, which I have been a part of

over time.   The reason I raise that is I look at the program

for tomorrow morning and there is a program of NIH talking

about its health services research agenda.   I think that is an

amazing change and I really think the folks here and the


                                40
organization had something to do with that change.       And i t is

obvious that you cannot translate the bench research from NIH

into the clinical area and out into the field without the kind

of work we have all done.     So that was an extraordinary sign -

to see that.

     Third, I want to make my second point which is -- I want

to leave one in case I need to make a --

     Male Voice:     Can I make one?

     Merwyn R. Greenlick:     Yes, but not mine [indiscernible due

to laughter].     You have to reserve some time.

     Robert J. Blendon:     I'm counting.

     Merwyn R. Greenlick:     The third point is sometimes, this

field is very personal and the notion that we do not have

grateful patients.     But what we do have, particularly those of

us that have worked in the demonstration area, I mean, I

started the first home health agency and a managed care program

in 1968.     I started what was probably the first pre-paid

Medicaid program that I managed.       It was actually the second;

Sam Shapiro started the first with the Old Age Assistance

Program in New York.     But those of us that have literally done

projects that have affected the lives of thousands feel that

sense.     They do not know that what we had to do with i t but we

know what we had to do with i t and that is very satisfying as

we look back.     And i t became particularly pointed to me as an


                                  41
individual, and I did this in the context of now being in the

legislature but at a personal level.       I understood how

important some of the work we have done.

       We have talked about care in the last year of life, and we

talked about this 10 percent that uses [sounds like] 60

percent.    I found myself in the position personally.        I was

diagnosed with lymphoma in the end of the 2005 session, a kind

of nasty version of it and I found myself in what my oncologist

thought was my last year of life.       But it turns out it was not

my last year of life because of the chemotherapy agents that

were developed by research, that are still being developed by

research, and the ability of my health care provider to pour

out about $150,000 into my care over what would have been my

last year of life and it turned out not to be.      And I am now

two-and-a-half years past that and I began to understand what

this last year of life means in a very different way.

       I had a similar experience and I want to end with this

because Bob Brook made a point that I think is the important

one.    I had a great two years.    I also fell, knocked the pads

off both my knees and I was laying in the road waiting for an

ambulance to come, knowing I could not straighten my legs, I

was figuring it was probably something wrong.      And started

asking myself, where was I going to ask the ambulance driver to

take me?    And I figured out where I was and then I said, "Well,


                                   42
I'm doing that because I have health insurance."     What if I did

not have health insurance?   And here I was, laying in the

street, turned out it was 30 minutes but you know, things got a

little screwed up in the system and playing what would have

happened if I did not have health insurance.

     Now, I told the story gaveling in my first meeting as

Chair of the Health Care Committee of the Oregon House of

Representatives.   And then redoubled my interest in how we have

to continue to move as CCNC did.      And I have been in that same

generation you are.    I have read all three, two of those

reports because they were sitting in the library in Michigan

how all of our lives are affected as individuals by the work we

do and it seems to me that is the satisfaction that we all

derive.

     The health care system is not something that happens to

somebody else, and the improvement our research has to the

health care system is not just something, it is helping those

people and those other people; it is helping all of us.      And

our involvement in health services research becomes very

personal when we understand those kinds of consequences.      So I

have been very happy to share the past quarter of a century

with my colleagues here and with the whole community we now

have of health service researchers because the field has

emerged in that way.


                                 43
        Robert J. Blendon:   Thank you.    It is a very special,

personal moment in that people here can ask some extraordinary

people their backgrounds, questions, you may never have them

exactly assembled together this way so we are hoping to take

any questions from the community here for all or any head

[sounds like] specifically.      I believe we have mies somewhere

in the audience.     Is that belief based on statistical evidence?

        Marsha R. Gold:   I'm not sure I have this question

formulated well enough for this panel but I wanted to pick up

on Ron's comment about data --

        Robert J. Blendon:   Just so we know who you are, just tell

everybody --

        Marsha R. Gold:   Oh, I'm sorry.   Marsha Gold, Mathematica

Policy Research, and I did hear a lot of those things when I

was in training and found them useful and do wonder why people

do not always know them today.

        But anyway, I want to pick up on Ron's comment that the

survey data gave us so much capacity and one of the challenges

that I see looking at organizational change - massive changes -

that right now, there is no data; that is the equivalent of

that.     And we end up in a situation where we often think, well,

how do we get the right treatment to the right patient through

the right doctor?     But it happens through a system, it happens

to an organization, it happens to a culture with a set of


                                   44
values.    Taking off where Bob Brook said that, you know, we

have done a lot, we have done some of the basic measurement,

where do people go next?     I would be interested in people's

thoughts on how we do address some of the tougher questions of

health services research that involve not just individual

access and its effects but how we get our institutions to move

in ways that do the things that our other research shows are

good for people?

     Robert J. Blendon:     [Indiscernible] do you want to

respond?    Larry?

     Lawrence S. Lewin:     I think i t raises an interesting

question that goes to the name of this organization.     As you

look at what persuades people to change policy, a lot of i t has

to do with a lack of conviction about how people will respond,

whether i t is physicians responding to payment systems or

individuals responding to incentives for taking care of

themselves.    And part of the problem is I think we tend to

think of health services research as having to do with the care

delivery system.     So I'm not suggesting that the organization

change its name, but I think the concept of focusing on health

and the health of the community and all that affects that

particularly from the standpoint of how individuals respond to

incentives, particularly to care for themselves, is an

important area that I think is going to get a lot of attention


                                  45
in the future.    And I'm not sure that health services

researchers think of that as being central to the field.

     Robert J. Blendon:    Bob, again?

     Robert Brook:     I'm going to take this a little

differently.     I could not agree more with the comments that

Mitch made about that.    We are people with health insurance

that talk about and work on trying to help other people get i t

or people that know how to get high-quality of care because we

think we can beat the system and then do research to help other

people that do not have the same connections that we have.       So

I'm going to take a crack at this a little differently.

     I think we have to have a new contract with the American

people.   You just cannot have a right for health insurance; you

have to have a responsibility.    And we have to reverse this

notion, this nonsense of privacy and security of data so that

everyone who gets health care - and we all get subsidized

health care - have to allow their data to be used in a way that

will advance medicine whether at the organizational level,

doing a survey, just like you have to participate in the

census, just like you have to take a driver's test to drive.          I

think we have to change and hopefully, in the next political

window, this rights-and-responsibility issue if we are going to

make any progress whatsoever.




                                  46
     The second thing is I think we are shooting ourselves in

the foot.    We have moved funding - i t has been true in every

administration but more in this administration - so that we

allow them to tell us that we cannot actually produce

information that is funded by taxpayers in the public domain.

I think we have a serious problem and I hope going forward, the

young people in this group will coalesce this organization and

demand that information work done under government contracts

and grants actually has to be made public as opposed to be

hidden.     And I think we are partly responsible for this because

we are all in this kind of a survival mode, still, of "If we do

not get i t and then do it, then we do not eat and if we do not

eat, then our families does not like us very much."     So I

really believe that we are going to have to do some serious

changes beyond just take advantage of the new political window,

[audio glitch] window that is going to open up, see if we can

change health policy.

     Robert J. Blendon:     Other questions?

     Male Voice:     Question, Bob, on your left.

     Robert J. Blendon:     Yes, we need an introduction to the

[indiscernible].

     Carolyn M. Clancy:     You wanted me to stand here so we

could move the camera from the panel to the questioner I think

to portray interaction.     First I wanted to say --


                                  47
        Male Voice:    You want to repeat that?

        Carolyn M. Clancy:    Yes.   I'm Carolyn Clancy from ARC.    I

wanted to say thanks to all of you for doing this.        I think

that for all the challenges we have ahead, I bet that back in

Chicago in the early meetings, you did not really envision a

meeting this huge with more and more young people coming in

every year, so thank you very much for that.

        I also had a comment/question.     So my suggestion actually

is I'm hoping that before you leave this meeting that you might

all get together and put in slips of paper into a time capsule

   I'm quite serious - that we could look at five, 10, for how

many years out.       And one issue in particular I would love to

see you address, which I do not think is subject for a glib

answer is: What does this future look like?        You are all got

into this, thinking that this was academic institutions and

think-tank-like organizations doing this stuff and bringing the

information to policymakers in a world where there is more and

more data available from health care delivery even from various

aspects directly affected by policy.

        I think a real question, taking Maggie's [phonetic]

challenge about implementation very seriously this morning is

she would be focused as much on building that kind of capacity.

Or do we simply end up funding the people who thought to do

that?     So there is no right or wrong answer, but I look forward


                                     48
to opening the time capsule from when this distinguished group

got together and made predictions about where we ought to be in

the future.

     Thank you.

     Merwyn R. Greenlick:    Bob, can I take a shot at that?

     Robert J. Blendon:     Sure, absolutely.

     Merwyn R. Greenlick:     I think Carolyn has really put a

finger on an important point and from a legislator's

perspective.   We are very clearly going to be pushing the

institutions in our state into making state-wide data available

from all the health care that is delivered.     We have a small

state, we have 3.5 million or so people but there is no

question, the collaboration among the health care delivery

system is going to be forced from the purchaser's perspective

and the state is the most important purchaser that we have.       We

are going to demand that.    We have created quality institutes

with the help of ARC and the Commonwealth and RWJ, and there is

no way that we are going to continue to put the kind of money

into the delivery system we put from the legislative

perspective without being able to do what Bob demands; without

being able to make sure we had the data that really allows us

to assess what is going on, and to force the kind of quality

improvement in the health care system that we as researchers




                                  49
know can happen if we have the data and the will to make it

happen.

     And I think the future is that across the states, we are

going to be developing the political will to make this kind of

information available in ways that it has never been available

in the past.    Twenty-five years from now, it will look

extraordinarily different.    We will be able to access the data

in the health care system and we will be able to change the way

care is delivered in the community because we will have the

information and the political will to do that.

     Clifton Gaus:    Let me add something to this also.   Bob

Brook and Bob Blendon will remember that our mentor always

asked, "What was the denominator?"    And today, I do not know

that we made a lot more progress in this country.    And in

building those databases with very good denominators, Kaiser

Permanente is clearly the leader in that regard.    There are, in

terms of a cross-section of our population, many health plans

that have continuous data - inpatient, outpatient - mined from

claims and able to do lots of things with it but is not shared

with anybody.   And the Medicare program stands out still, 40

years later, as the one program that has a denominator and that

has made that data available to the research community and you

think about what we have done with that, and the power of that.




                                 50
     And so, Carolyn, I do not know who we are speaking to

about this but if we could do one major thing, you know, to

push forward the knowledge of what we are doing, would be to

get a truly national -- even if i t is not a hundred, 200, 300

million people -- a national representative sample of total

utilization and a denominator to it.    We all dreamed 30 years

ago the National Health Insurance would do that.     But certainly

that has not happened and whatever plan we enact in the future

probably will not have that single source of data.     So the

research community does need to address that and put all the

force we can into forcing the owners of the data out there to

both share i t better and get better data.

     Robert J. Blendon:   A group that I work with just had a

very interesting meeting on electronic medical records and the

potential that electronic medical records, that however slowly

we are evolving to the point that they will be available in

fairly large amounts and the capacity of electronic medical

records to provide that kind of information.     I mean, i t will

not be perfect information.   We were debating the gold standard

of clinical trials on the one side, observational data that

comes out of claims on the other.     But the electronic medical

records are much better than the observational stuff that comes

out of claims.   While i t will not be perfect and i t will




                                 51
violate certain statistical properties, i t is going to be a

very powerful force.

     And one of the things that I think Barbara brought up and

I'll speak for Barbara because she is so shy, is she said in

many respects, we lack the methodology and the technique, that

we are still using techniques that were developed maybe in the

1920s.     Barbara gave us credit; I think she went as far as the

1970s.     And I think if anything, the research community needs

to develop a new set of techniques to make use of these data.

And we cannot keep on relying on old techniques.         But that data

will become available.

     Allen Dobson:     Al Dobson, Dobson/Davanzo.      Bob, this is

primarily to you.     You know as much as anybody [indiscernible­

speaks away from the microphone].

     Robert J. Blendon:     I cannot hear you.      I do not know very

much about mies, though.

     Allen Dobson:     It is on.   How is that?     Is that on now?

     Al Dobson, Dobson/Davanzo, and a question primarily to Bob

Blendon.     You know as much as anybody in the country about how

people think about health care.         We have all these folks at

this conference that know all these technical things, but i t

seems like there has to be a bridge between the folks out there

and the people at this conference with their technical stuff

before we can move [background noise] the basic question, all


                                   52
the rest of our basic questions.      How do we cover all those

uninsured?    Obviously, we have not done i t the past 20 years

Do you see any way at all we can make a bridge such that folks

get i t as we get i t that is the right thing to do?

     Robert J. Blendon:    The bottom line is yes.

     Allen Dobson:    Thank you, Bob.

     Robert J. Blendon:    So I would not be with my colleagues

for 25 years if I did not believe that was possible.      I surely

would not have stayed with this type of research I do if I did

not have some face to do this.     I want to slightly change just

the answers since you asked me versus my colleagues.

     Research -- we do not have a lot of is understanding the

basis that people who actually make decisions about these

issues, use on how they make decisions.      And for instance, in

other fields, take foreign policy.      We actually know more about

how Congress thinks about choices in foreign policy than we do

about our area.    We know about what we know, we know the facts

that we actually do not know how legislators and Congress weigh

evidence.    And the importance, after 25 years, is we produce

information for decision-makers who we often do not understand.

And so if you ask me what I would do here, is have a somewhat

better understanding -- so there is a whole field of research

in foreign policy.    When is i t important to Congress, how they

find it, what the constituents have to have, when the polls


                                 53
matter on foreign policy -- all these were done by academics.

They are not done.

     And you can have some understanding about the nth power of

what types of information and events.     But I feel we do not

know this.   We know something about clinicians, use that

information, but actually not decisions in the other -- and if

you are asking me what I would add to what we know is a better

understanding of who the user is and what are the constraints.

At breakfast this morning, Mitch talked about he had to learn a

whole new life in the legislature.     It was a different world

even though he was saying the issues are the same.     Well, that

is measurable and researchable to have a better understanding

of who uses and for decisions and under what circumstances.

     In terms of the American public, our colleague-cum­

foreteller [sounds like] people know very, very well, always

quotes Winston Churchill, that they will try everything.       And

ultimately, after they have tried everything they will actually

find the right thing to do.     So I have confidence we will

actually get there but I   [indiscernible] committee where -- let

me just take a couple more questions.

     Deborah K. Walker:    Hi, Debbie Walker.    I'm not sure if

I'm a health services researcher.      I started in as child

development, I mean up [sounds like] to associates now, with

the Public Health Department.    And I'm very curious to ask you


                                  54
guys a question about how you thought of the health services

research related to public health at the beginning and today.

I served as the immediate past president of the American Public

Health Association, 135 years old.       If we are going to produce

health, only 10 percent of health comes from what the medical

care system is doing.    Some of you alluded to this; that is why

I'm raising this question.     So I would like to say, necessary

but sufficient.   You could have the best universal, quality,

evidence-based health care system and we still will not produce

population health.   And that is going to take - I'm a

behavioral scientist -- that is going to take multiple

components, multiple sectors like we know with tobacco.

     So here is my question.    You all have really done a great

job at health services research.       How do we now -- or do you

see the future embracing more of a public health social

determinants model of health where we really can come together

in a bigger way to do that?    Because I always have looked at

this organization and I love these meetings as well as I like

all the other meetings as being really focused on one part of

that question.    So I see that as the challenge, moving forward,

to be able to integrate all that you have done and much more of

that framework community-participatory, multiple components,

and all the social determinants that produce health because it

is not just medical care.


                                  55
        Male Voice:   You know, I think, obviously from my comments

that I completely agree.       And I thought a lot about this.     In

fact, I'm working on a paper now on how HHS might be

reorganized to get a focus more on the health of Americans

rather than the health care delivery system.        And one of the

major changes and focus that will be necessary here is that we

have traditionally thought of ARC, and now increasingly NIH, as

being an area of lobbying and concern.        But CDC is a very, very

big part of this picture as well.        And CDC to some extent is

part of the problem because while they give money out to the

states, they do not do a lot of research on -- now, RWJ is

doing a lot now in terms of trying to invest in the public

health system by setting standards for performance and all the

rest.     I think the years ahead are going to see more of that

partially through the RWJ efforts and partially because what we

have learned is that efforts of preparedness have shown us that

it is not just the yearly preparedness for the public health

system is lacking, it is the entire system.        And there are

organizations working on this.       But I think that it is

important that we bring CDC into the picture here as well as

the leadership of HHS to broaden the focus to include mental

health as well as public health.

        Merwyn R. Greenlick:    Bob, I would like to make a point of

that, if I might.     The interesting issue relates to what Bob


                                    56
just said a moment ago.     The critical public health issues are

mostly political issues rather than scientific issues.     The two

most bruising challenges I had in the last session as chair of

the House Health Care Committee was a fight over fluoridation

of the water system and a fight over an increase in tobacco tax

which I was interested in, not because it funded health care

but because it would reduce adolescent smoking.     In both cases,

the argument had nothing to do with reality.     The fluoridation

issue, we were attacked by the right and the left.     The Sierra

Club using the worst kind of junk science that you can imagine

attacked it, as well as the radical right attacking it because

we were interfering with the life of their children or

something.     And the tobacco company brought - in little Oregon,

in a market of 3.5 million people - $13 million in the

campaign, again, full of lies, and spent $13 million defeating

an $0.85-a-pack cigarette tax.     So when we start getting into

the public health issues, we have a whole different set of

decisions that we have to be involved in and most of us are not

very well prepared as researchers to deal with those issues.

So we need to be involved with dealing with them as public

advocates, I think.

     Female Voice:     [Indiscernible - speaks away from the

microphone].

     Male Voice:     Yes.


                                  57
      Robert J. Blendon:    Yes, I think your point is well taken.

I think the single-most important thing we can do as a nation

to improve the health of the nation, to improve the urban

public school system and the cultural problems associated with

people not going to school and staying in school.     And I think

that a future for health service research frontier is making

that link because that is where the social investment has to

go.

      Gordon H. DeFriese:    I'm Gordon.   I think that this is an

excellent question that you have raised.      I think that if we

think back to where we were 25 years ago when this organization

started and we were meeting to try to figure out what to do and

why, I think that most of us were pretty desperate in those

days for funding of any kind to keep this field going.     We even

told the main national organization and federal agency greatly

threatened by and therefore, our future.     And so we were not

really so concerned about a lot of the issues so much as we

were how to keep the field alive.

      Now, I think when I came to this meeting and I got here, I

got my program this morning and started looking through it, I

was astounded how many sessions are on the topic of obesity.

And i t is not just on health care delivery but on the problem

of obesity in our society.     Three of us here on a panel in

Israel will be meeting in a couple of weeks and one of the


                                  58
things that is going on there is "Healthy Israel 2020" is being

planned very much like healthy people.   And one of the things

they think we have done here is figure out how to figure out

the cost and effectiveness of public health interventions which

we have not done very well.   But they want to learn from us but

where we have to share with them if what we did in medicine and

dentistry and so forth, but what they want to know is how do

you do this in tobacco cessation and other kinds of things.      So

I think that there should be or does need this kind of

attention.   But if we look at this program for this meeting, it

is a very different program than we ever imagined 25 years ago.

And I think in that regard, it does address some of the kinds

of issues I think you raised which are very important.

     William Pierskalla:   I would just like to second that.     I

really do believe that the transformation is there and the

young people are there and we have not kept up to them.      I

never would believe that one of my clinical scholars in the

year 2008 would be addressing the question: How do you provide

clean, cool drinking water to schoolchildren in urban Los

Angeles, not in an underdeveloped country.    There are no

standards, there is no ability to get it, there is no fountain

that works, and if you culture the fountain, the bottom line is

that it looks like a toilet bowl.    So the question is how do




                                59
you do this?    We are already there, I think.      I think how to

encourage that is very important.

     I think there are couple of points that have been missing

in this conversation, though.     And I think part of that is our

arrogance.     We all do come from academic backgrounds, a large

part of us in some science way.        And we believe in methods and

tools.   And how do you get somebody, an average American, to

understand what produces health and what is the health care

system if there is not a single lecture, course or textbook

that anyone as a schoolchild reads about it?       As far as I know,

this subject is not even covered.

     Mitch went into the legislature.        He knew something - at

least I think he knew something - about both health and health

services research and health systems, but by God, in the state

of California there is not one single physician in the

legislature.     And I do not know how many of those people, if

you actually did 101 of anything, understand even the basics

about how the delivery of health care systems works or the

production of health, and so one of my questions is to really

think about doing that last [sounds like].

     We are doing an experiment.       We are taking PhD-RAND

statisticians and we are going on into the community and trying

to figure out how they can relate to them and teach them what a

number is.     How do they use numbers in making a case?     I mean,


                                  60
the gulf between our researches and where people are is so

great now over methods that we really have to disrupt this

mechanism and try to get communication to be far better than

what i t currently is.

     Robert J. Blendon:   I want to honor my commitment to my

colleagues that we would break at this time.   I want to thank

everybody.   It is not normally the panel; i t is for their

contributions over 25 years.   As someone who gave that first

[indiscernible] address, I can tell you that I never envisioned

a field with this size, scale or importance.   Those of you at

universities know this has become a major centerpiece of

research policy from undergraduates to every professional

school.   It is extraordinarily due to many people in this

audience and the many people in this panel for you, for them,

and I agree with my colleagues, the lives we have actually

helped.   I thank very much for people who participated.

     [Applause]




                                61