How did you come to work in this field?
It's a long story! In college, I was interested in biology and psychology. And I went to law school but wasn't really interested in practising law. I went back to school and got a master's in public health and then worked in research at the National Academy of Sciences in Washington. I then returned to study in Boston and got a doctorate in psychology while looking for a way to combine the disciplines. First, I worked in public policy analysis for an insurance company and then with two large law firms, advising hospitals on healthcare transactions, insurance arrangements and managed care contracts. That led me to the health system of the University of Pennsylvania, which is built around a large teaching hospital similar to Pontchaillou in Rennes, and has a large network of hospitals and doctors. I was helping to bring doctors into the system.
Through the nineties, I was teaching health law as an adjunct professor. I enjoyed it very much. And then in 1999, I had the opportunity to go into full-time teaching at a small school called University of Sciences in Philadelphia, which was originally the Philadelphia College of Pharmacy. It had broadened from a pharmacy school to a health sciences university and asked me to create a programme in health policy. I built it from scratch. I was sort of an academic entrepreneur, and I did everything. I designed the curriculum, did the marketing, recruited students, and recruited faculty. It grew to become a department of the university.
In 2009, I had the opportunity to come to Drexel, which was growing as a university. It has a public health school that is now 15 years old and a law school that is now 10 years old. The law school chose health law as an area of focus. Drexel offered me a position between the two schools in public health and in law. Philadelphia, like Rennes I think, is very focused on education and healthcare, and the field I work in is at the intersection of the two. It's a natural place for me to work!
What brought you to Rennes?
My first contact was through the EHESP. There was a professor at Drexel who had spent time in Rennes through Europubhealth, a consortium of public health schools that is based at EHESP, under an Erasmus Mundus fellowship, and she encouraged some of our other faculty to apply. I was granted a fellowship in 2014. I spent a week in Copenhagen and a week in Rennes, where I participated in the year-end integration module for Europubhealth for students who had studied at campuses throughout Europe. I had a wonderful time!
Had you been to France before?
Yes, I'd been to France many times. My wife spent several months in France in college. She speaks French very well. We spent our honeymoon here. That came about because I was a graduate student at the time and had the opportunity to speak at a conference in Bourg-Saint-Maurice near Grenoble. We planned a trip around the conference. We visited many places including Provence but unfortunately missed the lavender fields in bloom. We'll have to go back to see them! I don't know if we decided that France would be our usual destination, but we keep coming back! (laughing).
As I explained, in 2014, I was in Rennes through an Erasmus Mundus fellowship. I came back in 2015 and 2016 for the year-end modules at Europubhealth and made two other trips to Rennes to lecture. I hope to come regularly for lectures in the fall and also to come in the spring to accompany student groups from Drexel. This is my 6th trip to Rennes.
Who comes to your lectures here?
They are students of Professor Marie-Laure Moquet-Anger, senior professor of health law, and of Catherine Keller, whom I will be working with. I have lectured in their classes on policies on vaccination and on non-profit hospitals in the United States.
What is the main difference between teaching French and American students?
I think the American students are more used to asking questions and challenging the professors. In law school, classes are meant to involve discussion, not just lectures. The professors expect students to speak up. And there's a tradition of calling on students and asking: What happened in this case? Students learn through discussion. I think that in France and most of Europe, it's more the lecture format.
I believe you try to bridge the gap between policy makers and research. Do you invite some policy makers in your lectures?
Yes. I taught a course this past spring and winter called Legal aspects of public health. I had an official from the federal Department of Health and Human Services who works on vaccine policy and I had a colleague, a professor, who was the health commissioner for the city of Philadelphia. In the fall, we invited, as a speaker, a former student of mine at University of the Sciences who had worked at the Office of Management and Budget, which is the budget analysis unit for the White House. Those are a few recent examples.
Do you follow public health reform in France?
A little. For my research with Catherine Keller, we will be looking at collaboration between for-profit and non-profit hospitals. There is a law that came into effect at the beginning of last year that encourages them to collaborate and to apportion services, and we will be studying that. I would like to learn more about the way the private and public sectors interact in France for hospitals and for insurance. I don't think it's as complicated as in the United States, but it's more complicated than I expected.
I wrote a book that came out about three years ago on the private health care sector in the United States and the way the government supports it in hidden ways. People think we have a for-profit, free-market healthcare system, but it wouldn't exist without strong and expensive government programmes. The National Institutes of Health, for instance. Its research is crucial for pharmaceutical companies in developing new drugs because the basic research it supports is something that private companies are not able to do.
Another example is our Medicare programme, which is healthcare for the elderly and disabled. It constitutes about half of the revenue of most hospitals. They couldn't exist if the government didn't provide this insurance because no private insurance company would cover the people who are old or disabled. However, that funding comes with many rules on how hospitals must operate. Medicare pays for training doctors, and its reimbursement creates incentives for doctors to go into different specialties. Some government policies are intentional and some are inadvertent, but all of them shape the way the private healthcare sector operates. I would say we really have a collaborative system, which many Americans don't realise. And so I'm interested in how that works in France.
Are there big differences between healthcare in the United States and in France?
I think the biggest difference is the entrepreneurial nature of healthcare in the United States. There are many more opportunities for doctors to be businessmen, to own clinics, to develop facilities, to operate laboratories in their offices, etc. I think in France, if you practice medicine, that's what you do. Hospitals in the United States, even when they are non-profit, have pressures to expand so we're seeing hospitals acquiring other hospitals. There are very few stand-alone hospitals left in the United States. They are almost all part of larger systems. There are fewer and fewer doctors who practice independently. Most of them now are in large groups, or they work for hospitals or insurance companies.
In the United States, some academic medical centres have become so big, they are like cities, more so than in France. In Philadelphia, they have built many high-rise buildings and spent millions of dollars on equipment. They are like cities of the future.
Another problem with health care in the United States is that doctors often fail to communicate with each other. A patient might see several specialists and be treated for different things, but the specialists don't communicate and discuss how the patient’s conditions may be related. So patients may be given drugs by one and then drugs by another that conflict. We're still working to have most doctors use electronic medical records. I think in France you're much more advanced in this regard. In the United States, each hospital has its own system, so if you go from hospital to hospital, it is difficult for any of them to see all of your records.
Much of the reason for the high level of health care spending in the United States is that hospitals are competing for patients. There's a lot of advertising! Billboards, television, magazines, newspapers, etc. If you go to a sports stadium, I would say about half of the advertisements are for something involving healthcare, perhaps a hospital or a clinic that does sports medicine or an insurance company.
It's a big business! They compete for patients and spend money on amenities to compete based on how beautiful the lobbies or the rooms are. The New York Times did a series of stories in which the question was: Is this a hospital or a hotel? And they would show the lobbies. It was impossible to tell the difference! In the United States, almost no one can afford to pay for health care on their own. Staying overnight in a hospital costs thousands of dollars, so it's the insurance companies that pay. A lot more is spent per patient because it's not their own money. The economists call this moral hazard: you are not careful if someone else is paying the bill. If your insurance company is paying the bill, you may decide: Why not have a television, a nice room, go to the fanciest hospital, stay as long as they'll let me and have all the tests I can get because I don't pay anything for it.
Professor Robert I. Field's profile on the Drexel University website can be found here.
Find out more about the Spring School which took place in March 2017.