By Anne M. Burton
Debbie Freund, President Emerita and Research Professor at Claremont Graduate University, was one of the first Medicaid scholars in the country. She has had a long and distinguished career, serving on the faculty at UNC Chapel Hill, Indiana University, Syracuse University, the Pardee RAND Graduate School, and the Fielding School of Public Health at UCLA. In this interview, we discuss how her interest in researching Medicaid came about, and how the profession has changed since her days as a graduate student.
Anne: Thank you for making the time to tell me about your successful and varied career. What was it like studying health economics when you first started out as a graduate student? And looking back, how would you say the profession has changed since then?
Debbie: In 1980 when I got my Ph.D. at The University of Michigan, I never thought I would become an academic and have a very satisfying career. So many things have changed since that time. There were virtually no concentrations or courses in health economics in economics departments and other than Marty Feldstein, no well-known scholars in the field. Looking back, one of the things that led to my success was always speaking up when I had a new idea. I learned that even if that idea was controversial, if you can explain your interest, it would never come back and haunt you.
When I suggested to my dissertation committee that I wanted to write my dissertation about the demand for medical care by race, they wondered what that had to do with economics. They approved the topic when I explained the potential role of health insurance on demand. I got my MPH in 1975, which is when I learned about health economics. It was in my MPH that I learned about health insurance and disparities which propelled my interest in this dissertation topic. At that time, Paul Feldstein, who taught the required health economics course in my MPH program, agreed to be on my dissertation committee and he eventually was chair of my dissertation committee. He was one of the first health economists at any university and in a School of Public Health at that time.
The MPH Program required that I take a summer internship. Usually, students were set up with mentors, alums who were CEOs of hospitals or insurance companies. I originally was matched with the CEO of the Blue Cross and Blue Shield association, but the CEO was a man, and I wanted to work for a woman, but no women were CEOs then, unlike now! I was matched with a graduate of the same program who ran the Medicaid program for New York State. The project she gave me to do was to see if I could negotiate with the 5 existing HMOs in the state so Medicaid beneficiaries could get their care there. I ended up being the first to do it in the nation and never had an idea of how big Medicaid Managed Care would become. That was an experience that really started my interest in understanding Medicaid. When I was doing the internship, I looked for articles on costs and utilization that would help me negotiate with the HMOs, but there were none.
Anne: You helped design the Medical Expenditure Panel Survey (MEPS), a longstanding survey that has been widely used by researchers interested in understanding health spending and health outcomes. How did that come about?
Debbie: The University of Michigan is well known for the development of surveys. So, when I was writing my dissertation, I asked if I could take some courses to learn how to develop surveys because I used a survey for my data. No one in economics thought it was a good idea except for a professor who ended up on my dissertation committee who ran the Panel Study of Income Dynamics (PSID). I became his research assistant on the PSID. One day, an alum of the economics department at Michigan, called the professor who ran the PSID and asked if he knew someone who could help her develop a survey focusing on medical care utilization and cost. That person was Gail Wilensky and we designed the precursor to the MEPS at what is now the Agency for Healthcare Research and Quality (AHRQ). I suggested that the survey which started out as a cross-sectional survey be turned into a panel study, which it was, after I left.
Anne: You are also one of the first scholars to do research on Medicaid. How did you get interested in Medicaid, what kinds of questions were you answering in the early days of Medicaid research, and what kind of data were you using to answer these questions?
Debbie: After I finished my dissertation, the woman who was the head of Medicaid in New York State went to work for Teddy Kennedy. Teddy reached out to me to understand about Medicaid Managed Care because many states were requesting 1115 waivers to try it out. As a result, what is now CMS and then was HCFA, asked me to read all the waiver requests and approve of ones that I thought were good ideas. Because of this, I ended up testifying to Congress about managed care and health care costs several times. One of the most important things I learned when testifying was that you had to explain things using very simple and understandable language. If one did not do this, one would have no impact on how Congress would think about things.
As a result, when I got to UNC, I got lots of grants to evaluate Medicaid Managed Care and whether outcomes and costs improved. That is how I started out my career as the first Medicaid scholar and made my name. To evaluate the success or lack of it of Medicaid Managed Care, we used claims data and occasionally developed surveys for specific states.
When I was at UNC, it was the beginning of the interdisciplinary era. To evaluate the success of Medicaid Managed Care, I wanted to do work with physicians and other faculty from different disciplines to look at Managed Care. But originally there was no approval to do so, because there was no way to share the indirect costs from grants and contracts with other schools. Thus, I helped the Vice President for Research figure out how to do this and he made it happen with Deans.
Anne: You’ve also made an impact on the profession beyond your research, including working in academic administration and serving as the interim Executive Director for ASHEcon. How did you get involved in those roles?
Debbie: I moved to Indiana University Bloomington when my husband, who is a labor economist whom I met at UNC, got offered a full professorship there. Jack Wennberg at Dartmouth, a well-known faculty physician, asked me if claims data could be used to study health outcomes and when I said they could, I ended up getting a multi-million-dollar PORT grant, Patient Outcomes Research Teams, a program that Dr. Wennberg set up at what is now AHRQ. I put together a team to study outcomes and costs of knee replacements which was the focus of our PORT grant. The problem was that like UNC, Indiana had no way to share indirect costs. That is when I was first asked to become an administrator because I worked it out at Indiana just like at UNC.
I never thought I would become a college Provost or President, but academic administration also led me to become the Executive Director of ASHEcon for a year. Also, due to administration, I have been on the Board of a Blue Cross and Blue Shield plan and many well-known hospitals. These are experiences I have enjoyed because of learning about different perspectives from other Board members. No boards ever had a health economist, so it was lots of fun to use my experience to point out new ideas, potential impacts, and new government ideas about things that would impact the institutions.
Anne: Those sound like very impactful experiences. Speaking of impactful experiences, tell me about the time you worked with the Australian government on drug pricing.
Debbie: Health economists do lots of research with a focus on learning about how policies can or should be changed, generally about reducing costs. One USA summer in the 1980s, I was visiting Australian National University and went to a wine tasting. I did not know anyone there, but it was fun to move around and meet new people. A person who came over to meet me and say hello was the Director of Australia’s Medicare Program, their National Health Insurance Program. He asked me a question indicating that there were only a few health economists in Australia, and he did not know them. He said that they had runaway drug costs in their national pharmaceutical formulary and asked what I might recommend they do about it. I had never thought about this issue but I recommended that when a pharmaceutical company wanted Australia’s Medicare to add a medication to its formulary, that they do comparative cost effectiveness analysis and price accordingly if there were similar drugs that were already covered. I also indicated that they should try to measure the value of the drug and price accordingly, if it was a new one and had no competitors. This person asked me to write a white paper about what I meant. I did not expect anything to happen because in those days in the USA, something like a white paper/report would sit on someone’s desk or on their computer. About 3 months later I got a phone call from the CEO of Eli Lilly who I knew because I was at Indiana University at the time. The CEO asked, with a little more colorful language, “what had I done. Did I want to bring down and ruin Eli Lilly?” I had no idea what he was talking about. As it turns out, without telling me, the Australian Government took my name off the Executive Summary of the document and legislated it without any changes. It is an idea that has spread all over the world and led me to consulting once for NICE in the UK and being on the Board of ICER, the Institute for Clinical and Economic Review in the United States. Once again, never be afraid to speak up if you have an idea.
Anne: Thank you for making the time to speak with me. Is there anything else you would like to mention?
Debbie: For those of you entering the field, you can never predict your future, but do not hesitate to do things that are of great interest because they will likely lead to new opportunities you can never imagine.