On cspan2. Great weather here all the time. [inaudible conversations] good morning. Welcome to the texas book festival. Im joined today by two incredible authors who are going to help us unpack American Health care. Katherine eban, who whens an investigative journalist, a Fortune Magazine contributor and an Andrew Carnegie fellow. Her articles on pharmaceutical counterfeiting, gun trafficking and coercive interrogations by the cia have Won International attention and numerous awards. She lectures frequently on the topic of pharmaceutical integrity, bottle of lies the inside story of the generic drug boom, her second book, was published bihar per collins in by harpercollins in may. Based on a decade of reporting, the book takes readers into manufacturing plants where the majority of our low cost generic medicine is made. Educated at Brown University and oxford where she was a rhodes scholar, eban lives in brooklyn with her husband, two daughters and newfoundland dog romeo. Dr. Marty makary works at Johns Hopkins university and author of the New York Times bestseller unaccountable an influential voice for physicians. He was the lead author of the articles introducing a surgical checklist adopted by the World Health Organization and has publishedded successfully on health care costs, vulnerable populations and quality science. He served in leadership at the World Health Organizations safe surgery saves lives project and has been elected to the National Academy of medicine. He lives here he lives in the washington, d. C. Area, and i think theres a tv series based on some of his writing. So for everyone here, were going to ask them some about their book. Thats going to be about 2530 minutes, then well take questions. So the last 015 minutes. 1015 minutes. Then in the first tent over, the books are for sale, and in the second tent over, therell be a book signing immediately following this at 11 45. So good morning, thank you for joining us. I was so fascinated, katherine, in reading about the story of the generic drug industry as you highlight the challenges with pharmaceuticals. Can you tell us a little bit about what it was like learning about the challenges that they have there with oversight, fraud, and a little bit about how you learned about it and if you had any fear in telling the story that was challenging and maybe dangerous . Well, its great to be here and thank you, deborah, for those terrific questions. So bottle of lies a corporate crime story. And it takes readers deep into the overseas plants that make our low cost, mostly generic medicine. The project began in 2008 when i was contacted, actually, by a radio show host who has an npr radio program, the peoples farm i. He said pharmacy. He said all these patients are contacting me complaining about their generic drugs, either strange side effects or lack of effects. He was concerned, and he had taken those complaints to the fda, and their response was, well, it must be psychosomatic because if patients are changed from either one generic to another or from a brand to generic and they see a pill thats a different color or size, they may have a reaction. But joe graden, whos the radio show host, did not buy that, and he posted questions he posed a question to me, what is wrong with the drugs . And that question launched me on a decadelong reporting odyssey. And though i started with the patients and the doctors, my reporting led me to other continents. It led me to india, to china, to africa as i began to probe what was happening in the distant manufacturing plants that are making our drugs. And what i learned is that there is endemick fraud in these endemic fraud in these plants. Often highly concealed and difficult to discern, but many of these plants are faking quality data that or altering data that they then submit to regulators in order to get a approval to market their drugs. So, you know, one of the central questions is what does this mean for all of us, and what it really means for american patients and others around the world is that we may be getting drugs that are not actually bioequivalent, that might contain toxic impurities, metallic fragments or particles. But in essence, as i said, the book is really a corporate crime story because im exposing through internal documents, emails and the stories of executives in these companies the profit motive that they have to alter this data and get their drugs on the market. And as far as fear, yes, i definitely had [laughter] fear throughout this project. You know, i really, when i began realizing that my reporting was going to take me to india and china, i just had this moment of not moment, maybe years how am i going to do. That how am i, as a solo journalist, going to figure out what is going on in these countries where aye never reported where ive never reported, where i dont have any sources. Of and thats probably why the book ended up taking me ten years. I mean, i did on the ground reporting, cultivated sources, interviewed whistleblowers, got internal documentation and, ultimately, the book is based on 20,000 internal documents from the fda that i got through a source. So that is the story of interim deliberations, emails internal deliberations, emails and all kinds of regulatory decisions that rarely get publicly exe posed. Thank you. So, commissioner gottlieb of the fda has done a great job at escalating generic drug approvals. And you talk in your book quite a bit about the generic drug approval process and the accelerates new drug application accelerated new drug application. I was surprised to learn in the book about the decrease in necessary requirements that can lead to changes in directs of a drug changes in distribution of a drug over time. For example, with well buy flynn when it was well buy flynn when it was made generically. Can you talk about the dangers as you do in your book about some of the challenges in distributing a drug over a shorter period of time, and then do you have suggestions of the way the fda could move from its limited oversight to something more to correct upon the status quo . So let me, thats a great question with a lot of parts, but let me try to address it by talking about, first, profit motives and then regulatory systems. So when there was a law called hatchwaxman which passed in 984 which basically gave the generic truck industry its start the drug industry its start. One of the questions the drug industry had was, well, if im going to go ahead and manufacture a generic and i dont know if its going to get approved and im going to have to sue the Brand Name Company and thats going to be expensive, wheres the deal sweetener . So there is a deal sweetener that was put into hatchwaxman called first to file. Basically said the firstier generic drug company that gets through the door of the fda with its application and gets approved gets six months of exclusivity on the u. S. Market without competitors. So just to give you a especially of how big that is a sensing of how big that is, an Indian Company got a first to file on generic lipitor. In 24 hours it made 100 million. Over six months it was worth 600 million. So in the generic drug industry, it is a the difference between making a fortune and making a living. Because they wanted to be first, as i discovered, there were literally tent cities that sprouted in the fda parking lot, and companies that would bring their executives in in stretch limos oversight where they would take turns sleeping and waiting on line all to be first through the door of the fda. And when a line would form, there were sometimes fistfights where one company would push another Company Executive out of the way because you had to be first in the door and put your application down. So the profit motive is intense. So thats number one. Then theres the problem of regulation. When the fda sends its investigators into u. S. Plants to inspect, they show up unannounced which you would assume would be the gold standard, right . You dont tell them youre coming, you just show up. But overseas, because it is difficult and complicated, they have a very different system. They will announce their inspection sometimes two months in advance. They will contact these plants and say will you please invite us, wed like to come, and will you arrange Ground Transportation and hotel accommodations. So the investigators show up as invited guests of these companies which then literally have two months to alter, fabricate documents. In one plant that i document, they invented Standard Operating Procedures which theyre supposed to have and then steamed the documents overnight in a room, in a kind of saunalike room to make them look old for when the fda showed up. So the level of subterfuge which i describe in the book is really remarkable. So in answer to your question how do we fix this goat rodeo, clearly the fda needs to not tell these companies that theyre coming. And if that is complicated and difficult because the companies are overseas, we should be saying to foreign governments, you know what . You want entry into our market, this is going to be the requirement. This will be the standard. Which is, were going to show up unannounced. So at the moment what we have, which is really pretty shocking, is an hornbased honorbased regulatory system. It might surprise some people in the audience to know that the fda is not even systematically testing our drugs. What theyre doing is theyre looking at data that the Company Submits in order to determine whether theyre going to approve, and then the they do these preannounced inspections to make sure the plants are okay. I will say one more thing which is the fda did do a limited experiment in india where they called it a Pilot Program where for a year and a half they showed up unannounced. No advance notice, only short notice or no notice. What they discovered was incredible. Once they got rid of that advance notice, they were finding snake and lizard infestations, pigeon droppings all over the place, bathrooms with no drainage piping inner the apriling sanitary areas in sterile, sanitary areas so you can just figure out the rest of it yourself. [laughter] and so these are the kinds of conditions that have a direct impact on the quality and sterility of the drug, and they have to be exposed. Thank you, katherine. And were going to come back to that honorbased system in a moment. Im going to pivot to marty, dr. Makary now, and talk a little bit about his book. I have to say as a doctor, i found it really troubling in reading your first chapter, i had chest pain reading about some of the perverse incentives and some of the unwarranted variation that you see in care. Can you tell everyone about that . Because i was surprised by some of the things that you characterized, and i think thats kauaiopening for folks eyeopening for folks. Well, thank you, dr. Pratt, and its great to be here and great to learn from katherine here too, and i hope those medications are not the ones im prescribing. [laughter] well, you might be. Probably. Great. What a system. [laughter] and its great to be here in texas. I love austining, so thanks for having me. You know, i think the stories that we need to talk about that no one talking about are the areas in health care where theres broad consensus among the american people. So if we can turn off cable news for a little bit and stop listening to the echo chambers that were a dividedded cup on Health Care Country on health care, i would submit to you that theres broad consensus that we need to fix the problems that katherine just describedded, that we need to end corruption, that we need to stop the disproportionate representation of a small, select group of special interests. When theres a pothole in a town, its not a blue reddish shoe, its a we e ten city issue. And in health care, the areas where i think there is broad consensus are pricing and the appropriateness of care. And our Research Shows that were doing way too much. We asked doctors around the country what prosecute of what percent of medical care in your observations, excluding the ox vegases of your own observations of your own practice, are unnecessary. And they replied an average answer of 21 . 22 of medications, unnecessary. 11 of medical procedures. I was at a conference of neurosurgeons that do Spine Surgery, and they were telling me that they believe that half of all Spine Surgery for back pain in the United States is up up is unnecessary. I dont know, im not a spine surgeon, im a pancreas surgeon. But if theyre correct, we have a serious crisis of appropriateness. After all, isnt the Opioid Epidemic just one manifestation of that crisis with one medication . There are many other medications that weve overprescribed also sometimes with good intentions and bad science. But i chose to open the book with the story that a local cardiologist told me of doctors going to the local churches to recruit patients for stents in their legs to open up plaques of the leg arteries or narrowing in the leg artery. Well, it turns out that theres very little science to support a lot of it. And people often times are no symptoms have no symptoms, and yet theyre being screened in churches. This was predominant in the enter under the auspices of a health fair in the auspices of providing free health screamings by these local groups screenings. And what they were doing was they were recruiting for unnecessary procedures. So i told that story, and i find with health care weve got to tell positive stories. And i was privileged to tell the stories. I have so many disrupters in health care, it was exciting for me to learn, to travel to meet these folks and to present a solution with every problem. But with this problem, i wanted people to realize at the beginning that throwing more money into the system does not fix it. We already spend enough money to give everybody within our borders great health care. We just need to cut the waste. And the politicians really are talking about different ways to finance the broken health care system, not how to fix the broken health care system. And if you fix it, we have to get at these issues of pricing failures and the appropriateness of care. You know, if airlines billed us after the flight and didnt show prices [laughter] they would be price gouging. You take a direct flight to chicago and you might get e a bill for 4,000. And they would argue we cant give you a price, we dont know if theres going to be a delay, or the pilot may have to bill for turbulence and work harder and more complex medical coding after they land. And you might get a surprise bill for 500 for consuming a beverage. [laughter] we would say, look, we can get our act together, as the Airline Industry has, and Price Services so we have a healthy, competitive marketplace that would end this horrible practice of price gouging in health care today which im concerned is now eroding the great public trust in our great profession. Thank you. I felt like as a doctor your story really resonated with me. We do a lot of work in valuebased care, but i felt like most importantly the consumers need to read this book because without opening their eyes to some of the ways in which there can be perverse incentives or to question their physicians, that it would be hard for them to have a path that was better for their health. Can you talk a little bit about particularly the cardiology story was one that was interesting to me, and ill say theres publicly documented challenges of that in texas. Im sure probably everywhere. Where patients may get unnecessary cardiac stents when they may not require that, sometimes 20 or more. Can you talk a little about that story and then, as a consumer, how you can be more discriminating about what you need for health care and what you dont . Sure. It is i think were not going to have the government Fix Health Care. We, the american people, are going to Fix Health Care by demanding more honesty. And doctors and hospitals have a history of being honest and delivering honesty with patients. And if we understand that 20 of Second Opinions are different from the first opinion some studies suggest it may be as high as 3040 you should get a Second Opinion when youre told you need something major. Now, look, if you have a gunshot wound to the chest and we need to do an emergency thoracotomy, just do what we tell you [laughter] and dont get a Second Opinion. And were never going to give you a price in those spanish situations in those situations, we just need to take care of you. But when youre told, hey, you might need an open heart surgery or you might need a stent or you might need a spine procedure or a knee otter pscopy, those are opportunities to educate yourself, get a Second Opinion. We dont want to create hysteria, but people should know there is wide variation in quality in health care. Even within the same hospital sometimes. And so i like to push the field. I think we need to do that in health care. I think sometimes weve become a medical establishment where weve become content with the status quo. Arguing that its not a good system, but weve not really challenged it. I think too many of us just collect our paycheck every two weeks and complain about the system, and we really need to speak up. When i suggested we should have public informing for infection rates and basic quality measures i was told this was crazy, radical and hospitals simply cant do it. And i promoted this in the book unaccountable. Well, a few years later it became standard, and nobody when we suggested if it were a disease that was ranked as the third leading cause of death in the United States, we were criticized. Within six months the story started to come out of children dying in their car because their parent was on opioids, and opioids within a year became the number one cause of death in people under 50 in the United States. Isnt that simply one manifestation of medical care gone wrong . And in the case of the opening chapter of the book of doctors putting stents in leg arteries, we found that the United States Preventive Services task force condemns any prif vascular peripheral vascular screen thing. So when people are told we have some leg pain, hey, we want to come in and take a look, they should be aware of one of those patterns where we doctors are concerned about overuse within our profession. And ill say the many examples that you give in the book, the need for back surgery and undergoing that prior to attemptive physical therapy or a cardiac stent or the leg stents for painful legs, as you mentioned, all of those are just some samples of things that i think will allow patients to be better consumers of their care as we all need to be asking more questions and to try, when its reasonable, to take less invasive ways to improve. Katherine, back to, back to your book, in revisiting that issue of depending upon honest accountability, i see that, one, the generic drug industry has grown tremendously. Probably there isnt a person in this room that is not on a generic drug and a drug manufacturer in a different country. You talk about many of the challenges in outsourcing to that degree, because its hard to hold individuals accountable if they may only eat one meal a day and their cultural norms and expectations about quality work product are so different than they are here in the United States. Can you talk a little bit about what some of those challenges are and if you think that there is a way that we can continue to export drug manufacturing in a safe way . So, you know, as i was reporting the book, one thing that that i heard a lot about was the issue of culture and how Corporate Culture impacts behavior in manufacturing plants, and country culture can also impact conduct in manufacturing plants. So, you know, one of the difficulties is we now get, just as an example, 40 of our finished generics come from india. Theyre made there. So, and a lot of these plants are just in the hinterlands of india where companies are actually employing, for example, illiterate farmers to doer the april manufacturing to do sterile manufacturing aztec in additions. And, you know, these are people who dont have training. There is a very strong caste system in india, so there is not the sort of habit and practice of telling the boss no. But theres also much weaker whistleblower protections. So, you know, some i should say that some of the heroes of this book and the p main whistleblower in this book is indian with, but if youre going to be a whistleblower in india, you have no legal protection. It may be, in fact, just a death sentence to complain about practices, and you also dont have a competent regulator to complain to. So, you know, we have outsourced or are relying on Manufacturing Systems that are culturally quite different than they are in the u. S. And that is not to say that there is no fraud in u. S. Plants. Thats not true. Its also not to say that theres fraud in theres no fraud in brand name plants. Thats also not true. But just if you look at the system, i mean, one fda investigator said to me, you know, when i started investigating these plants, my question is how did anybody in this country ever think that this system was going to work . You know, you have, you have herbally debunked regulators in india who are, see their role more as being in the service of industry, you know . They rarely show up, and youve got these companies where in order to sign documents, theyre putting charts up on the wall to just show their workers what to write down. Thats whats going on in these plants. So, you know, by and large, its a system that seems absolutely designed to fail us. I also just with want to say briefly in terms of what marty was saying about what consumers understand or know about these systems, it is critical that consumers get educated about what is actually going on. One fda consultant told me, you know, if you have a consumer who goes out to buy cheddar cheese, they understand that there is a quality difference between velveeta, kraft or artisal ched bar, right . In every tie they go to a pharmacy, there is a quality choice embedded in the kind of Prescription Drug they take and who the manufacturer is makes a difference as far as the quality of that drug. They are not necessarily all interchangeable, as the fda has promised us. Fascinating. And, marty, can you tell us the one glimmer of hope that i had well, there are actually several glimmers of hope, but the big glimmer of hope that i had in reading your book was the promise of Quality Control. Youve obviously been a pioneer in that in surgery trying to make sure that surgery call checklists can diminish some of the unanticipated errors that you can see in surgery. Can you talk about the role of Quality Control and that emerging from medicine . If you ever think theres a role for that to be publicly transparent . I think quality science is a very complex science, and if its done in a poor or mediocre way, it can be counterproductive and create perverse incentives. So i personally have been an advocate for practice pattern measurement; that is, lets get off the backs of docs who are trying to practice and tailor treatments to their patients. After all, medicine is an art, and treatments should be customized to your goals and specific situations. Lets get rid of these barriers, you know, with all the time, the peertopeer and preauthorizations that dont make sense that bog us down and drive burnout, and lets look at patterns. Lets look at the surgeons, for example, who operate on back pain when none of their patients in their entire practice over the course of the year have seen a physical therapist within a year preceding the back surgery. These are patterns in big data that are measurable, that are there, our Research Team has access to them. Weve published many of them. In your own field of breast care, one of them is that the breast doctors offered is the breast reexcision rate after initial lumpectomy. If youre calling 10 or 20 of your patients back saying we didnt get all the cancer, we need to take another surgical excision, that is the normal rate at which an undetected area of cancer can be seen on the lumpectomy specimen. But if youre at 50 or 60 , doctors in that specialty say theres no way to justify it. Thats way too high. That doctor needs help. And so weve gone around to meet with different doctor groups in the country who are practicing not just in the ivory tower and not just at the university, but those on the ground in the United States and rural and small hospitals as well as those who are leaders in the Academic Centers asking them, tell us about a pattern of overuse that we can measure in big data. Sometimes it needs to be done that way so we can pull apart doctors when they are within the normal boundaries of variation. Get off their backs and let them Practice Medicine, let us Practice Medicine and spend those resources helping outliers as we did in a project with skin set cancer surgery, the doctors told us doctors who take out too many blocks four stages per case, that is the removing ofcancer with four or five blocks on average of specimens rather than one or two which is average. They still per block, so in an area of abuses picking out too many. When we let outliers know that there outliers, 83 percent reduce their pattern of overuse immediately with confidential. Doctor report cards. It was civility, it was reminding people why we went into medicine and they auto corrected and that project which cost 150,000 in medicare 27 million and were seeing massive improvements when we can look at patterns and share data back with doctors, letting them know your outside of whatsconsidered reasonable your peers. Can we help you and were doing it for opioid prescribing , doctors are still out there prescribing 30 opioid pills after a routine lumpectomy. We should be getting ibuprofen and acetaminophen with local anesthetic. These are patterns of overuse that we can measure, we should measure and were starting to measure with incredible results and that is one of the story i was privileged to tell in the book we are going to move now to your questions, so theres a microphone up here in front and also in back so please truck to move to those microphones if you have a question and ill call on you. As we have folks moving to the microphone ill say that these books are going to surprise you. I think they are must reads for everyconsumer. Problem lies does read like a john grisham brother. Even though you knew who done it already and the compilation of various stories and the price we pay was so fascinating that i felt like my parents need to read this. Everyone is engaging with healthcare needs to read this. We have a question upfront. I was reading about a lady who took charge of administrating ahospital in denver. And she changed how they managed the hospital and she actually forced themto figure out what did the procedure cost . How much time should be spent and she cut the cost of that hospital like 30 percent without any impact on care. And she used some of the methods that toyota uses when they build polity into their cars so i guess the question is how do we incentivize hospitals and doctors to think about how theyre running the operation to keep the costs down without hurting quality . Or even be transparent about price. The only reason those hospitals are doing that is because people like you and americans are demanding prices for basic services. For elective services, you need to demand a price and heres a secret from industry, those prices are highly negotiable before during and after the care and if you dont like your bill, go to your doctor. Dont worry about botheringus. We need to be engaged because when we found when we told doctors that their patients have been gouged and sued in court sometimes, to have their paycheck garnished, a waitress taking a second job because the hospital garnished her paycheck and this is going on around the country, youre defending patients in court. We went hundred percent of the time were asking hospitals to stop suing patients. The hospital that sued25,000 people in a town of 28,000 by census data. That i described in the book after the book im proud to report they stopped all lawsuits and my visit with these folks, 50 percent of americans have less than 400 of cash in savings. They dont live like us. We need to remember that these gains, the money gains are threatening the great public trust in american hospitals and we need to rebuild that trust with honest pricing. [applause] thats great. The nextquestion. Appreciate you. It does seem to me that you are, the general discussion is putting a lot of the onus on the consumer. A lot of us are reasonably welleducated, a lot of us are not well educated but even for the more welleducated its tough to navigate our wage through all of this and i did hear dumping that was a little bit discouraging to me and that is that there are very limited roles for the government and all of this and if we keep this more or less in the capitalist enterprise state, the commercial that we see for drugs for example, an example of where this all could go though i like you just to think a little bit and talk just a bit about where you see the role for government in helping us straighten this all out because i think we can think bigger rather than smaller but id like to see an opinion on that. Ill start by saying that in the case of substandard generics that are pharmaceuticals, the role for the government is very clear which is to improve its regulatory system and to stop with the kind of honor based faithbased regulatory system and do the kinds of inspections and routine testing that is going to verify what is in the drug. So thats clear, but i will say when consumers have more information, so for example we have, you know where your groceries come from. You know where your clothing is made because it tells you on the label. You have no idea whereyour drugs are manufactured. If we were to create transparency there and have country of origin labeling both or active ingredient and finished drugs, that could have a marked effect because if consumers are saying i would rather take a drug thats manufactured in theusa , i think you might see some sort of shift and a return to manufacturing youre athome. [applause] do you want to comment to mark. Ill say briefly we have good people in healthcare. We have greatpeople leading american hospitals but they are working in a bad system. We have inherited this crazy game of inflating prices for the purpose of offering secret insurance discounts and now people are getting it with those prices but weve never had to produce real prices before. And thats the exciting movement now if you go to mdc. Com, you can look up prices at their health. Org. All sorts of ways now where were starting to see a revolution in honest prices. Id love to see more tries transparency across the board. Our next question. You talked extensively about the negligence of foreign practices that go into these things, exacerbating these drugs and the concern of course for differential healthoutcomes. The product, the pill , but i guess the question im interested in is what is the sophistication . There are millions of bills entering the country and in terms of chemicals, molecular analysis of the actual bill, can you detect the outcomes of these negligent practices . It would seem that is the variable or a process that should be of keen importance in terms of seeing what outcomes are before these drugs areadministered to patients. Let me First Respond to that with just an example of what is happening in asystem where there is no routine testing. An sba investigator went into a plant in china in 2017 and noticed something which was that plant, beijing huahei was not investigating impurity spiked drugs. Itwas making Blood Pressure medicine for the us market. So the investigator recommended to the fda this should be a serious sanction on this manufacturing plant, its called official action indicated. The bureaucrats back in maryland that it doesnt seem serious. It will make it voluntary action indicated. They downgraded the recommendation. The plant wasnt sanctioned. Fastforward one year and it turns out that plant was producing active ingredients for Blood Pressure medication that had a carcinogen and it called mdma. So this was a case where the fda investigator connie, the bureaucrats at fda said not such a big deal. It works routinely testing the drug and here we are. Millions of americans having Blood Pressure medication as been recalled. So you can do routine and systematic testing for carcinogens, or impurities. You can do dissolution and stability testing. Its not simple, its not cheap, but i think that we should demand that is i think the system of simply looking at data on paper to figure out whether a drug passes muster is obviously inadequate. And there are millions of americans who have and up taking one pressure medication for years that contained this carcinogen, and dna. This will be our last question. Our Canadian Drug being imported in the same way that american drugs are . Our Canadian Drugs being imported in the same way american drugs are imported . So our Canadian Drugs beingimported in the same way . Theres a couple different issues with Canadian Drugs . One option, politicians who are desperate to announce that they have lower drug prices are always turning to the solution of importation. But if we just sort of built outside of this fda system and we import from a country that has lower drug prices, that will solve all our problems. So importation is an issue that is on the table in a big way right now. I have some concerns about that because i think even though the fda system needs an overhaul, i think once you go outsideof that system, youre inviting a lot of risk. And i think that Canadian Drugs have kind of taken on this mythic notion for american consumers. Well, to the north theres snow up there, the drugs must be pure and white. And i have to say i think thats a little bit of a canard. And often for american consumers, if youre going online and youre buying from a canadian pharmacy, probably somewhere in the fine print its going to say if we dont happen to have the drug in stock, your authorizing us to purchase this drug our offshore partners and i will just tell you this, you never want a drug and offshore partner. So i think that in a way, Canadian Drugs are a bit of a red herring or a white herring, whatever you want to call it and we need to work on fixing our system of oversight regulation and pricing here at home. Thank you and we just have a few minutes left. Ill ask doctor max lee one more question. If you talk about the limitations and the challenges that we have an unnecessary variability and perverse incentives, it seems like the call to quality and recording dashboard reporting, telling physician from physician whats happening as we all just need a nudge to improve. We all want to be better looking smarter than average. So where do you see transparency going in medicine mark i know there have been a lot of discussions about Price Transparency. It can be easier for commodity Like Services like the cdc. Do you see efforts to become more transparent . So consumers can makebetter apples to apples comparisons and how do we get there . I think a quality metric has to be mature and endorse for doctors practicing in the area in order to be used for anything with public reporting. I got that pretty closely. Price transparency ushers in quality transparency but theres one tv for 500 bucks in your town, the question is do i buy it or not . If theres two tvs, one for 501for 600, what do you say . I want to know all the specs and the detail on the longterm outcomes so Price Transparency and invites quality transparency so the most exciting thing ive seen in healthcare are these new relationship based clinics that are sprouting up all across the country. Theyre growing like wildfire. Doctors now rejecting the billing throughput model of care that we hate and patience take. And spending time with both and using a team and in talking about food as medicine and treating diabetes with cooking classes and managing back pain with ice and physical therapy instead of surgery and opioids. These clinics are growing all over america and take the form of direct primary care, medicaid managed plans, jen care, street. They are revolutionizing healthcare and patience are bringing in bags of medication because they dont need them anymore once we address these roots underlying issues that drive our crazy cost crisis elements. Thank you for a wonderful discussion and foryour wonderful contribution. [applause] if youd like to join us over at the book signing tent, its too over and if you need to pick up books on the way, are in the first 10 over
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